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Huang P, Liu F, Hu X, Li B, Xu X, Liu Q. Effect of ultrashort-acting β-blockers on 28-day mortality in patients with sepsis with persistent tachycardia despite initial resuscitation: a meta-analysis of randomized controlled trials and trial sequential analysis. Front Pharmacol 2024; 15:1380175. [PMID: 38966549 PMCID: PMC11222614 DOI: 10.3389/fphar.2024.1380175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 05/20/2024] [Indexed: 07/06/2024] Open
Abstract
Purpose This meta-analysis aims to identify whether patients with sepsis who have persistent tachycardia despite initial resuscitation can benefit from ultrashort-acting β-blockers. Materials and methods Relevant studies from MEDLINE, the Cochrane Library, and Embase were searched by two independent investigators. RevMan version 5.3 (Cochrane Collaboration) was used for statistical analysis. Results A total of 10 studies were identified and incorporated into the meta-analysis. The results showed that the administration of ultrashort-acting β-blockers (esmolol/landiolol) in patients with sepsis with persistent tachycardia despite initial resuscitation was significantly associated with a lower 28-day mortality rate (risk ratio [RR], 0.73; 95% confidence interval [CI], 0.57-0.93; and p˂0.01). Subgroup analysis showed that the administration of esmolol in patients with sepsis was significantly associated with a lower 28-day mortality rate (RR, 0.68; 95% CI, 0.55-0.84; and p˂0.001), while there was no significant difference between the landiolol and control groups (RR, 0.98; 95% CI, 0.41-2.34; and p = 0.96). No significant differences between the two groups were found in 90-day mortality, mean arterial pressure (MAP), lactate (Lac) level, cardiac index (CI), and troponin I (TnI) at 24 h after enrollment. Conclusion The meta-analysis indicated that the use of esmolol in patients with persistent tachycardia, despite initial resuscitation, was linked to a notable reduction in 28-day mortality rates. Therefore, this study advocates for the consideration of esmolol in the treatment of sepsis in cases where tachycardia persists despite initial resuscitation.
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Affiliation(s)
- Po Huang
- Beijing Dongfang Hospital, Beijing University of Traditional Chinese Medicine, Beijing, China
| | - Fusheng Liu
- Beijing Dongfang Hospital, Beijing University of Traditional Chinese Medicine, Beijing, China
| | - Xiao Hu
- Beijing Dongfang Hospital, Beijing University of Traditional Chinese Medicine, Beijing, China
| | - Bo Li
- Beijing Hospital of Traditional Chinese Medicine, Affiliated with Capital Medical University, Beijing, China
- Beijing Institute of Traditional Chinese Medicine, Beijing, China
| | - Xiaolong Xu
- Beijing Hospital of Traditional Chinese Medicine, Affiliated with Capital Medical University, Beijing, China
- Beijing Institute of Traditional Chinese Medicine, Beijing, China
| | - Qingquan Liu
- Beijing Hospital of Traditional Chinese Medicine, Affiliated with Capital Medical University, Beijing, China
- Beijing Institute of Traditional Chinese Medicine, Beijing, China
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Antonucci E, Garcia B, Legrand M. Hemodynamic Support in Sepsis. Anesthesiology 2024; 140:1205-1220. [PMID: 38743000 DOI: 10.1097/aln.0000000000004958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
This review discusses recent evidence in managing sepsis-induced hemodynamic alterations and how it can be integrated with previous knowledge for actionable interventions in adult patients.
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Affiliation(s)
- Edoardo Antonucci
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco, San Francisco, California; Department of Anesthesia and Critical Care Medicine, University of Milan, Milan, Italy
| | - Bruno Garcia
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco, San Francisco, California; Department of Intensive Care, Centre Hospitalier Universitaire de Lille, Lille, France; Experimental Laboratory of Intensive Care, Université Libre de Bruxelles, Brussels, Belgium
| | - Matthieu Legrand
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco, San Francisco, California; INI-CRCT (Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists) Network, Nancy, France
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Hotz E, van Gemmern T, Kriege M. Are We Always Right? Evaluation of the Performance and Knowledge of the Passive Leg Raise Test in Detecting Volume Responsiveness in Critical Care Patients: A National German Survey. J Clin Med 2024; 13:2518. [PMID: 38731046 PMCID: PMC11084342 DOI: 10.3390/jcm13092518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/22/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
Background: In hemodynamically unstable patients, the passive leg raise (PLR) test is recommended for use as a self-fluid challenge for predicting preload responsiveness. However, to interpret the hemodynamic effects and reliability of the PLR, the method of performing it is of the utmost importance. Our aim was to determine the current practice of the correct application and interpretation of the PLR in intensive care patients. Methods: After ethical approval, we designed a cross-sectional online survey with a short user-friendly online questionnaire. Using a random sample of 1903 hospitals in Germany, 182 hospitals with different levels of care were invited via an email containing a link to the questionnaire. The online survey was conducted between December 2021 and January 2022. All critical care physicians from different medical disciplines were surveyed. We evaluated the correct points of concern for the PLR, including indication, contraindication, choice of initial position, how to interpret and apply the changes in cardiac output, and the limitations of the PLR. Results: A total of 292 respondents participated in the online survey, and 283/292 (97%) of the respondents completed the full survey. In addition, 132/283 (47%) were consultants and 119/283 (42%) worked at a university medical center. The question about the performance of the PLR was answered correctly by 72/283 (25%) of the participants. The limitations of the PLR, such as intra-abdominal hypertension, were correctly selected by 150/283 (53%) of the participants. The correct effect size (increase in stroke volume ≥ 10%) was correctly identified by 217/283 (77%) of the participants. Conclusions: Our results suggest a considerable disparity between the contemporary practice of the correct application and interpretation of the PLR and the practice recommendations from recently published data at German ICUs.
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Affiliation(s)
| | | | - Marc Kriege
- Department of Anaesthesiology, University Medical Centre, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (E.H.); (T.v.G.)
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Xiang H, Zhao Y, Ma S, Li Q, Kashani KB, Peng Z, Li J, Hu B. Dose-related effects of norepinephrine on early-stage endotoxemic shock in a swine model. JOURNAL OF INTENSIVE MEDICINE 2023; 3:335-344. [PMID: 38028636 PMCID: PMC10658043 DOI: 10.1016/j.jointm.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/20/2023] [Accepted: 06/20/2023] [Indexed: 12/01/2023]
Abstract
Background The benefits of early use of norepinephrine in endotoxemic shock remain unknown. We aimed to elucidate the effects of different doses of norepinephrine in early-stage endotoxemic shock using a clinically relevant large animal model. Methods Vasodilatory shock was induced by endotoxin bolus in 30 Bama suckling pigs. Treatment included fluid resuscitation and administration of different doses of norepinephrine, to induce return to baseline mean arterial pressure (MAP). Fluid management, hemodynamic, microcirculation, inflammation, and organ function variables were monitored. All animals were supported for 6 h after endotoxemic shock. Results Infused fluid volume decreased with increasing norepinephrine dose. Return to baseline MAP was achieved more frequently with doses of 0.8 µg/kg/min and 1.6 µg/kg/min (P <0.01). At the end of the shock resuscitation period, cardiac index was higher in pigs treated with 0.8 µg/kg/min norepinephrine (P <0.01), while systemic vascular resistance was higher in those receiving 0.4 µg/kg/min (P <0.01). Extravascular lung water level and degree of organ edema were higher in animals administered no or 0.2 µg/kg/min norepinephrine (P <0.01), while the percentage of perfused small vessel density (PSVD) was higher in those receiving 0.8 µg/kg/min (P <0.05) and serum lactate was higher in the groups administered no and 1.6 µg/kg/min norepinephrine (P <0.01). Conclusions The impact of norepinephrine on the macro- and micro-circulation in early-stage endotoxemic shock is dose-dependent, with very low and very high doses resulting in detrimental effects. Only an appropriate norepinephrine dose was associated with improved tissue perfusion and organ function.
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Affiliation(s)
- Hui Xiang
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan 430071, Hubei, China
| | - Yuqian Zhao
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan 430071, Hubei, China
| | - Siqing Ma
- Department of Critical Care Medicine, Qinghai Provincial People's Hospital, Xining 810007, Qinghai, China
| | - Qi Li
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan 430071, Hubei, China
| | - Kianoush B. Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Zhiyong Peng
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan 430071, Hubei, China
| | - Jianguo Li
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan 430071, Hubei, China
| | - Bo Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan 430071, Hubei, China
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Alvarado Sánchez JI, Caicedo Ruiz JD, Diaztagle Fernández JJ, Cruz Martínez LE, Carreño Hernández FL, Santacruz Herrera CA, Ospina-Tascón GA. Variables influencing the prediction of fluid responsiveness: a systematic review and meta-analysis. Crit Care 2023; 27:361. [PMID: 37730622 PMCID: PMC10510289 DOI: 10.1186/s13054-023-04629-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 08/27/2023] [Indexed: 09/22/2023] Open
Abstract
INTRODUCTION Prediction of fluid responsiveness in acutely ill patients might be influenced by a number of clinical and technical factors. We aim to identify variables potentially modifying the operative performance of fluid responsiveness predictors commonly used in clinical practice. METHODS A sensitive strategy was conducted in the Medline and Embase databases to search for prospective studies assessing the operative performance of pulse pressure variation, stroke volume variation, passive leg raising (PLR), end-expiratory occlusion test (EEOT), mini-fluid challenge, and tidal volume challenge to predict fluid responsiveness in critically ill and acutely ill surgical patients published between January 1999 and February 2023. Adjusted diagnostic odds ratios (DORs) were calculated by subgroup analyses (inverse variance method) and meta-regression (test of moderators). Variables potentially modifying the operative performance of such predictor tests were classified as technical and clinical. RESULTS A total of 149 studies were included in the analysis. The volume used during fluid loading, the method used to assess variations in macrovascular flow (cardiac output, stroke volume, aortic blood flow, volume‒time integral, etc.) in response to PLR/EEOT, and the apneic time selected during the EEOT were identified as technical variables modifying the operative performance of such fluid responsiveness predictor tests (p < 0.05 for all adjusted vs. unadjusted DORs). In addition, the operative performance of fluid responsiveness predictors was also influenced by clinical variables such as the positive end-expiratory pressure (in the case of EEOT) and the dose of norepinephrine used during the fluid responsiveness assessment for PLR and EEOT (for all adjusted vs. unadjusted DORs). CONCLUSION Prediction of fluid responsiveness in critically and acutely ill patients is strongly influenced by a number of technical and clinical aspects. Such factors should be considered for individual intervention decisions.
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Affiliation(s)
- Jorge Iván Alvarado Sánchez
- Fundación Santa Fe de Bogotá, Department of Intensive Care, Bogotá, Colombia.
- Department of Physiology Sciences, Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia.
| | - Juan Daniel Caicedo Ruiz
- Department of Physiology Sciences, Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Juan José Diaztagle Fernández
- Department of Physiology Sciences, Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
- Department of Internal Medicine, Fundación Universitaria de Ciencias de La Salud. Hospital de San José, Bogotá, Colombia
| | - Luís Eduardo Cruz Martínez
- Department of Physiology Sciences, Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | | | | | - Gustavo Adolfo Ospina-Tascón
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
- Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad Icesi, Cali, Colombia
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Murgolo F, Mussi RD, Messina A, Pisani L, Dalfino L, Civita A, Stufano M, Gianluca A, Staffieri F, Bartolomeo N, Spadaro S, Brienza N, Grasso S. Subclinical cardiac dysfunction may impact on fluid and vasopressor administration during early resuscitation of septic shock. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2023; 3:29. [PMID: 37641139 PMCID: PMC10463881 DOI: 10.1186/s44158-023-00117-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/21/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND According to the Surviving Sepsis Campaign (SSC) fluids and vasopressors are the mainstays of early resuscitation of septic shock while inotropes are indicated in case of tissue hypoperfusion refractory to fluids and vasopressors, suggesting severe cardiac dysfunction. However, septic cardiac disfunction encompasses a large spectrum of severities and may remain "subclinical" during early resuscitation. We hypothesized that "subclinical" cardiac dysfunction may nevertheless influence fluid and vasopressor administration during early resuscitation. We retrospectively reviewed prospectically collected data on fluids and vasoconstrictors administered outside the ICU in patients with septic shock resuscitated according to the SSC guidelines that had reached hemodynamic stability without the use of inotropes. All the patients were submitted to transpulmonary thermodilution (TPTD) hemodynamic monitoring at ICU entry. Subclinical cardiac dysfunction was defined as a TPTD-derived cardiac function index (CFI) ≤ 4.5 min-1. RESULTS At ICU admission, subclinical cardiac dysfunction was present in 17/40 patients (42%; CFI 3.6 ± 0.7 min-1 vs 6.6 ± 1.9 min-1; p < 0.01). Compared with patients with normal CFI, these patients had been resuscitate with more fluids (crystalloids 57 ± 10 vs 47 ± 9 ml/kg PBW; p < 0.01) and vasopressors (norepinephrine 0.65 ± 0.25 vs 0.43 ± 0.29 mcg/kg/min; p < 0.05). At ICU admission these patients had lower cardiac index (2.2 ± 0.6 vs 3.6 ± 0.9 L/min/m2, p < 0.01) and higher systemic vascular resistances (2721 ± 860 vs 1532 ± 480 dyn*s*cm-5/m2, p < 0.01). CONCLUSIONS In patients with septic shock resuscitated according to the SSC, we found that subclinical cardiac dysfunction may influence the approach to fluids and vasopressor administration during early resuscitation. Our data support the implementation of early, bedside assessment of cardiac function during early resuscitation of septic shock.
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Affiliation(s)
- Francesco Murgolo
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Rossella di Mussi
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Antonio Messina
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Humanitas University, Pieve Emanuele-Milano, Italy
| | - Luigi Pisani
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Lidia Dalfino
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Antonio Civita
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Monica Stufano
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Altamura Gianluca
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Francesco Staffieri
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Nicola Bartolomeo
- Interdisciplinary department of medicine, University of Bari, Bari, Italy
| | - Savino Spadaro
- Department of translation medicine, University of Ferrara, Ferrara, Italy
| | - Nicola Brienza
- Interdisciplinary department of medicine, University of Bari, Bari, Italy
| | - Salvatore Grasso
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy.
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Monnet X, Lai C, Ospina-Tascon G, De Backer D. Evidence for a personalized early start of norepinephrine in septic shock. Crit Care 2023; 27:322. [PMID: 37608327 PMCID: PMC10464210 DOI: 10.1186/s13054-023-04593-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 07/28/2023] [Indexed: 08/24/2023] Open
Abstract
During septic shock, vasopressor infusion is usually started only after having corrected the hypovolaemic component of circulatory failure, even in the most severe patients. However, earlier administration of norepinephrine, simultaneously with fluid resuscitation, should be considered in some cases. Duration and depth of hypotension strongly worsen outcomes in septic shock patients. However, the response of arterial pressure to volume expansion is inconstant, delayed, and transitory. In the case of profound, life-threatening hypotension, relying only on fluids to restore blood pressure may unduly prolong hypotension and organ hypoperfusion. Conversely, norepinephrine rapidly increases and better stabilizes arterial pressure. By binding venous adrenergic receptors, it transforms part of the unstressed blood volume into stressed blood volume. It increases the mean systemic filling pressure and increases the fluid-induced increase in mean systemic filling pressure, as observed in septic shock patients. This may improve end-organ perfusion, as shown by some animal studies. Two observational studies comparing early vs. later administration of norepinephrine in septic shock patients using a propensity score showed that early administration reduced the administered fluid volume and day-28 mortality. Conversely, in another propensity score-based study, norepinephrine administration within the first hour following shock diagnosis increased day-28 mortality. The only randomized controlled study that compared the early administration of norepinephrine alone to a placebo showed that the early continuous administration of norepinephrine at a fixed dose of 0.05 µg/kg/min, with norepinephrine added in open label, showed that shock control was achieved more often than in the placebo group. The choice of starting norepinephrine administration early should be adapted to the patient's condition. Logically, it should first be addressed to patients with profound hypotension, when the arterial tone is very low, as suggested by a low diastolic blood pressure (e.g. ≤ 40 mmHg), or by a high diastolic shock index (heart rate/diastolic blood pressure) (e.g. ≥ 3). Early administration of norepinephrine should also be considered in patients in whom fluid accumulation is likely to occur or in whom fluid accumulation would be particularly deleterious (in case of acute respiratory distress syndrome or intra-abdominal hypertension for example).
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Affiliation(s)
- Xavier Monnet
- AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU 4 CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, Université Paris-Saclay, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.
| | - Christopher Lai
- AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU 4 CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, Université Paris-Saclay, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Gustavo Ospina-Tascon
- Department of Intensive Care Medicine, Fundación Valle del Lili, Av. Simón Bolívar Cra. 98, Cali, Colombia
- Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad ICESI, Cali, Colombia
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
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Chen H, Liang M, He Y, Teboul JL, Sun Q, Xie J, Yang Y, Qiu H, Liu L. Inspiratory effort impacts the accuracy of pulse pressure variations for fluid responsiveness prediction in mechanically ventilated patients with spontaneous breathing activity: a prospective cohort study. Ann Intensive Care 2023; 13:72. [PMID: 37592166 PMCID: PMC10435426 DOI: 10.1186/s13613-023-01167-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 08/01/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND Pulse pressure variation (PPV) is unreliable in predicting fluid responsiveness (FR) in patients receiving mechanical ventilation with spontaneous breathing activity. Whether PPV can be valuable for predicting FR in patients with low inspiratory effort is unknown. We aimed to investigate whether PPV can be valuable in patients with low inspiratory effort. METHODS This prospective study was conducted in an intensive care unit at a university hospital and included acute circulatory failure patients receiving volume-controlled ventilation with spontaneous breathing activity. Hemodynamic measurements were collected before and after a fluid challenge. The degree of inspiratory effort was assessed using airway occlusion pressure (P0.1) and airway pressure swing during a whole breath occlusion (ΔPocc) before fluid challenge. Patients were classified as fluid responders if their cardiac output increased by ≥ 10%. Areas under receiver operating characteristic (AUROC) curves and gray zone approach were used to assess the predictive performance of PPV. RESULTS Among the 189 included patients, 53 (28.0%) were defined as responders. A PPV > 9.5% enabled to predict FR with an AUROC of 0.79 (0.67-0.83) in the whole population. The predictive performance of PPV differed significantly in groups stratified by the median value of P0.1 (P0.1 < 1.5 cmH2O and P0.1 ≥ 1.5 cmH2O), but not in groups stratified by the median value of ΔPocc (ΔPocc < - 9.8 cmH2O and ΔPocc ≥ - 9.8 cmH2O). Specifically, in patients with P0.1 < 1.5 cmH2O, PPV was associated with an AUROC of 0.90 (0.82-0.99) compared with 0.68 (0.57-0.79) otherwise (p = 0.0016). The cut-off values of PPV were 10.5% and 9.5%, respectively. Besides, patients with P0.1 < 1.5 cmH2O had a narrow gray zone (10.5-11.5%) compared to patients with P0.1 ≥ 1.5 cmH2O (8.5-16.5%). CONCLUSIONS PPV is reliable in predicting FR in patients who received controlled ventilation with low spontaneous effort, defined as P0.1 < 1.5 cmH2O. Trial registration NCT04802668. Registered 6 February 2021, https://clinicaltrials.gov/ct2/show/record/NCT04802668.
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Affiliation(s)
- Hui Chen
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
- Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Soochow University, No. 899 Pinghai Road, Suzhou, 215000 People’s Republic of China
| | - Meihao Liang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
- Department of Critical Care Medicine, Changsha central hospital, University of South China, No. 161, South Shaoshan Road, Changsha, 410000 Hunan People’s Republic of China
| | - Yuanchao He
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
- Department of Critical Care Medicine, Wuhan first hospital of Hubei Province, No 215 Zhongshan Avenue, Qiaokou District, Wuhan, 430000 People’s Republic of China
| | - Jean-Louis Teboul
- Service de médecine intensive-réanimation, Hôpital de Bicêtre, Université Paris-Saclay, AP-HP, Inserm UMR S_999, Le Kremlin-Bicêtre, France
| | - Qin Sun
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
| | - Jianfen Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
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Hamzaoui O, Goury A, Teboul JL. The Eight Unanswered and Answered Questions about the Use of Vasopressors in Septic Shock. J Clin Med 2023; 12:4589. [PMID: 37510705 PMCID: PMC10380663 DOI: 10.3390/jcm12144589] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/05/2023] [Accepted: 07/08/2023] [Indexed: 07/30/2023] Open
Abstract
Septic shock is mainly characterized-in addition to hypovolemia-by vasoplegia as a consequence of a release of inflammatory mediators. Systemic vasodilatation due to depressed vascular tone results in arterial hypotension, which induces or worsens organ hypoperfusion. Accordingly, vasopressor therapy is mandatory to correct hypotension and to reverse organ perfusion due to hypotension. Currently, two vasopressors are recommended to be used, norepinephrine and vasopressin. Norepinephrine, an α1-agonist agent, is the first-line vasopressor. Vasopressin is suggested to be added to norepinephrine in cases of inadequate mean arterial pressure instead of escalating the doses of norepinephrine. However, some questions about the bedside use of these vasopressors remain. Some of these questions have been well answered, some of them not clearly addressed, and some others not yet answered. Regarding norepinephrine, we firstly reviewed the arguments in favor of the choice of norepinephrine as a first-line vasopressor. Secondly, we detailed the arguments found in the recent literature in favor of an early introduction of norepinephrine. Thirdly, we reviewed the literature referring to the issue of titrating the doses of norepinephrine using an individualized resuscitation target, and finally, we addressed the issue of escalation of doses in case of refractory shock, a remaining unanswered question. For vasopressin, we reviewed the rationale for adding vasopressin to norepinephrine. Then, we discussed the optimal time for vasopressin administration. Subsequently, we addressed the issue of the optimal vasopressin dose, and finally we discussed the best strategy to wean these two vasopressors when combined.
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Affiliation(s)
- Olfa Hamzaoui
- Service de Médecine intensive réanimation polyvalente, Hôpital Robert Debré, CHU de Reims Université de Reims, 51092 Reims, France
- "Hémostase et Remodelage Vasculaire Post-Ischémie"-EA 3801, Unité HERVI, 51100 Reims, France
| | - Antoine Goury
- Service de Médecine intensive réanimation polyvalente, Hôpital Robert Debré, CHU de Reims Université de Reims, 51092 Reims, France
| | - Jean-Louis Teboul
- Service de médecine intensive-réanimation, Hôpital de Bicêtre, AP-HP, Université Paris-Saclay, DMU CORREVE, FHU SEPSIS, 94270 Le Kremlin-Bicêtre, France
- INSERM-UMR_S999 LabEx-LERMIT, Hôpital Marie-Lannelongue, 92350 Le Plessis Robinson, France
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10
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Carlos Sanchez E, Pinsky MR, Sinha S, Mishra RC, Lopa AJ, Chatterjee R. Fluids and Early Vasopressors in the Management of Septic Shock: Do We Have the Right Answers Yet? J Crit Care Med (Targu Mures) 2023; 9:138-147. [PMID: 37588181 PMCID: PMC10425929 DOI: 10.2478/jccm-2023-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/22/2023] [Indexed: 08/18/2023] Open
Abstract
Septic shock is a common condition associated with hypotension and organ dysfunction. It is associated with high mortality rates of up to 60% despite the best recommended resuscitation strategies in international guidelines. Patients with septic shock generally have a Mean Arterial Pressure below 65 mmHg and hypotension is the most important determinant of mortality among this group of patients. The extent and duration of hypotension are important. The two initial options that we have are 1) administration of intravenous (IV) fluids and 2) vasopressors, The current recommendation of the Surviving Sepsis Campaign guidelines to administer 30 ml/kg fluid cannot be applied to all patients. Complications of fluid over-resuscitation further delay organ recovery, prolong ICU and hospital length of stay, and increase mortality. The only reason for administering intravenous fluids in a patient with circulatory shock is to increase the mean systemic filling pressure in a patient who is volume-responsive, such that cardiac output also increases. The use of vasopressors seems to be a more appropriate strategy, the very early administration of vasopressors, preferably during the first hour after diagnosis of septic shock, may have a multimodal action and potential advantages, leading to lower morbidity and mortality in the management of septic patients. Vasopressor therapy should be initiated as soon as possible in patients with septic shock.
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Affiliation(s)
- E. Carlos Sanchez
- Department of Critical Care Medicine, King Salman Hospital, Riyadh, Saudi Arabia
| | - Michael R. Pinsky
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sharmili Sinha
- Department of Critical Care Medicine, Apollo Hospitals, Bhubaneswar, India
| | - Rajesh Chandra Mishra
- Department of Critical Care Medicine, Ahmedabad Khyati Multi-speciality Hospitals, Ahmedabad, India Department of Critical Care Medicine, Ahmedabad Shaibya Comprehensive Care Clinic, Ahmedabad, India
| | - Ahsina Jahan Lopa
- ICU and Emergency Department, Shahabuddin Medical College Hospital, Dhaka, Bangladesh
| | - Ranajit Chatterjee
- Department of Critical Care Medicine, accident and emergency, Swami Dayanand Hospital Delhi, India
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11
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Garcia B, Legrand M. Adjunctive vasopressors in distributive shock: How soon is early? Crit Care 2023; 27:210. [PMID: 37254175 DOI: 10.1186/s13054-023-04500-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 06/01/2023] Open
Affiliation(s)
- Bruno Garcia
- Department of Anesthesia & Peri-Operative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA.
- Department of Intensive Care, Centre Hospitalier Universitaire de Lille, Lille, France.
- Experimental Laboratory of Intensive Care, Université Libre de Bruxelles, Brussels, Belgium.
| | - Matthieu Legrand
- Department of Anesthesia & Peri-Operative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
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12
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Demailly Z, Besnier E, Tamion F, Lesur O. Ventriculo-arterial (un)coupling in septic shock: Impact of current and upcoming hemodynamic drugs. Front Cardiovasc Med 2023; 10:1172703. [PMID: 37324631 PMCID: PMC10266274 DOI: 10.3389/fcvm.2023.1172703] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/08/2023] [Indexed: 06/17/2023] Open
Abstract
Sepsis is an archetype of distributive shock and combines different levels of alterations in preload, afterload, and often cardiac contractility. The use of hemodynamic drugs has evolved over the past few years, along with the invasive and non-invasive tools used to measure these components in real time. However, none of them is impeccable, which is why the mortality of septic shock remains too high. The concept of ventriculo-arterial coupling (VAC) allows for the integration of these three fundamental macroscopic hemodynamic components. In this mini review, we discuss the knowledge, tools, and limitations of VAC measurement, along with the evidence supporting ventriculo-arterial uncoupling in septic shock. Finally, the impact of recommended hemodynamic drugs and molecules on VAC is detailed.
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Affiliation(s)
- Zoé Demailly
- Medical Intensive Care Unit, UNIROUEN, INSERM U1096, CHU Rouen, Normandie Université, Rouen, France
- Department of Anesthesiology and Critical Care, UNIROUEN, INSERM U1096, CHU Rouen, Normandie Université, Rouen, France
| | - Emmanuel Besnier
- Department of Anesthesiology and Critical Care, UNIROUEN, INSERM U1096, CHU Rouen, Normandie Université, Rouen, France
| | - Fabienne Tamion
- Medical Intensive Care Unit, UNIROUEN, INSERM U1096, CHU Rouen, Normandie Université, Rouen, France
| | - Olivier Lesur
- Centre de Recherche Clinique du CHU Sherbrooke, Sherbrooke, QC, Canada
- Départements de Soins Intensifs et de Médecine et Service de Pneumologie, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
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13
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Dugar S, Siuba MT, Sacha GL, Sato R, Moghekar A, Collier P, Grimm RA, Vachharajani V, Bauer SR. Echocardiographic profiles and hemodynamic response after vasopressin initiation in septic shock: A cross-sectional study. J Crit Care 2023; 76:154298. [PMID: 37030157 DOI: 10.1016/j.jcrc.2023.154298] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/10/2023]
Abstract
PURPOSE Vasopressin, used as a catecholamine adjunct, is a vasoconstrictor that may be detrimental in some hemodynamic profiles, particularly left ventricular (LV) systolic dysfunction. This study tested the hypothesis that echocardiographic parameters differ between patients with a hemodynamic response after vasopressin initiation and those without a response. METHODS This retrospective, single-center, cross-sectional study included adults with septic shock receiving catecholamines and vasopressin with an echocardiogram performed after shock onset but before vasopressin initiation. Patients were grouped by hemodynamic response, defined as decreased catecholamine dosage with mean arterial pressure ≥ 65 mmHg six hours after vasopressin initiation, with echocardiographic parameters compared. LV systolic dysfunction was defined as LV ejection fraction (LVEF) <45%. RESULTS Of 129 included patients, 72 (56%) were hemodynamic responders. Hemodynamic responders, versus non-responders, had higher LVEF (61% [55%,68%] vs. 55% [40%,65%]; p = 0.02) and less-frequent LV systolic dysfunction (absolute difference -16%; 95% CI -30%,-2%). Higher LVEF was associated with higher odds of hemodynamic response (for each LVEF 10%, response OR 1.32; 95% CI 1.04-1.68). Patients with LV systolic dysfunction, versus without LV systolic dysfunction, had higher mortality risk (HR(t) = e[0.81-0.1*t]; at t = 0, HR 2.24; 95% CI 1.08-4.64). CONCLUSIONS Pre-drug echocardiographic profiles differed in hemodynamic responders after vasopressin initiation versus non-responders.
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Affiliation(s)
- Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Matthew T Siuba
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | | | - Ryota Sato
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ajit Moghekar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Patrick Collier
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA; Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, USA
| | - Richard A Grimm
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA; Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, USA
| | - Vidula Vachharajani
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA; Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, USA
| | - Seth R Bauer
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA; Department of Pharmacy, Cleveland Clinic, USA.
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14
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Lindén A, Statkevicius S, Bonnevier J, Bentzer P. Blood volume in patients likely to be preload responsive: a post hoc analysis of a randomized controlled trial. Intensive Care Med Exp 2023; 11:14. [PMID: 36997730 PMCID: PMC10063697 DOI: 10.1186/s40635-023-00500-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 02/10/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Preload responsive postoperative patients with signs of inadequate organ perfusion are commonly assumed to be hypovolemic and therefore treated with fluids to increase preload. However, preload is influenced not only by blood volume, but also by venous vascular tone and the contribution of these factors to preload responsiveness in this setting is unknown. Based on this, the objective of this study was to investigate blood volume status in preload-responsive postoperative patients. METHODS Data from a clinical trial including postoperative patients after major abdominal surgery were analyzed. Patients with signs of inadequate organ perfusion and with data from a passive leg raising test (PLR) were included. An increase in pulse pressure by ≥ 9% was used to identify patients likely to be preload responsive. Blood volume was calculated from plasma volume measured using radiolabelled albumin and hematocrit. Patients with a blood volume of at least 10% above or below estimated normal volume were considered hyper- and hypovolemic, respectively. RESULTS A total of 63 patients were included in the study. Median (IQR) blood volume in the total was 57 (50-65) ml/kg, and change in pulse pressure after PLR was 14 (7-24)%. A total of 43 patients were preload responsive. Of these patients, 44% were hypovolemic, 28% euvolemic and 28% hypervolemic. CONCLUSIONS A large fraction of postoperative patients with signs of hypoperfusion that are likely to be preload responsive, are hypervolemic. In these patients, treatments other than fluid administration may be a more rational approach to increase cardiac output. Trial registration EudraCT 2013-004446-42.
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Affiliation(s)
- Anja Lindén
- Anesthesiology and Intensive Care, Department of Clinical Sciences Lund, Helsingborg Hospital, Lund University, Helsingborg, Sweden.
| | - Svajunas Statkevicius
- Intensive and Perioperative Care, Department of Clinical Sciences Lund, Skane University Hospital, Lund University, Lund, Sweden
| | - Johan Bonnevier
- Intensive and Perioperative Care, Department of Clinical Sciences Lund, Skane University Hospital, Lund University, Lund, Sweden
| | - Peter Bentzer
- Anesthesiology and Intensive Care, Department of Clinical Sciences Lund, Helsingborg Hospital, Lund University, Helsingborg, Sweden
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15
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Kandels J, Metze M, Hagendorff A, Marshall RP, Hepp P, Laufs U, Stöbe S. The impact of upright posture on left ventricular deformation in athletes. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2023; 39:1123-1131. [PMID: 36869240 DOI: 10.1007/s10554-023-02820-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/16/2023] [Indexed: 03/05/2023]
Abstract
Besides LV ejection fraction (LVEF), global longitudinal strain (GLS) and global myocardial work index (GWI) are increasingly important for the echocardiographic assessment of left ventricular (LV) function in athletes. Since exercise testing is frequently performed on a treadmill, we investigated the impact of upright posture on GLS and GWI. In 50 male athletes (mean age 25.7 ± 7.3 years) transthoracic echocardiography (TTE) and simultaneous blood pressure measurements were performed in upright and left lateral position. LVEF (59.7 ± 5.3% vs. 61.1 ± 5.5%; P = 0.197) was not affected by athletes' position, whereas GLS (- 11.9 ± 2.3% vs. - 18.1 ± 2.1%; P < 0.001) and GWI (1284 ± 283 mmHg% vs. 1882 ± 247 mmHg%; P < 0.001) were lower in upright posture. Longitudinal strain was most frequently reduced in upright posture in the mid-basal inferior, and/or posterolateral segments. Upright posture has a significant impact on LV deformation with lower GLS, GWI and regional LV strain in upright position. These findings need to be considered when performing echocardiography in athletes.
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Affiliation(s)
- J Kandels
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Germany.
| | - M Metze
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - A Hagendorff
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - R P Marshall
- RasenBallsport Leipzig GmbH, Cottaweg 3, 04177, Leipzig, Germany
- Department of Orthopedic and Trauma Surgery, Martin-Luther-University Halle-Wittenberg, 06120, Halle, Germany
| | - P Hepp
- Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - U Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - S Stöbe
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
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16
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Dorninger F, Kiss A, Rothauer P, Stiglbauer-Tscholakoff A, Kummer S, Fallatah W, Perera-Gonzalez M, Hamza O, König T, Bober MB, Cavallé-Garrido T, Braverman NE, Forss-Petter S, Pifl C, Bauer J, Bittner RE, Helbich TH, Podesser BK, Todt H, Berger J. Overlapping and Distinct Features of Cardiac Pathology in Inherited Human and Murine Ether Lipid Deficiency. Int J Mol Sci 2023; 24:1884. [PMID: 36768204 PMCID: PMC9914995 DOI: 10.3390/ijms24031884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/10/2023] [Accepted: 01/11/2023] [Indexed: 01/21/2023] Open
Abstract
Inherited deficiency in ether lipids, a subgroup of glycerophospholipids with unique biochemical and biophysical properties, evokes severe symptoms in humans resulting in a multi-organ syndrome. Mouse models with defects in ether lipid biosynthesis have widely been used to understand the pathophysiology of human disease and to study the roles of ether lipids in various cell types and tissues. However, little is known about the function of these lipids in cardiac tissue. Previous studies included case reports of cardiac defects in ether-lipid-deficient patients, but a systematic analysis of the impact of ether lipid deficiency on the mammalian heart is still missing. Here, we utilize a mouse model of complete ether lipid deficiency (Gnpat KO) to accomplish this task. Similar to a subgroup of human patients with rhizomelic chondrodysplasia punctata (RCDP), a fraction of Gnpat KO fetuses present with defects in ventricular septation, presumably evoked by a developmental delay. We did not detect any signs of cardiomyopathy but identified increased left ventricular end-systolic and end-diastolic pressure in middle-aged ether-lipid-deficient mice. By comprehensive electrocardiographic characterization, we consistently found reduced ventricular conduction velocity, as indicated by a prolonged QRS complex, as well as increased QRS and QT dispersion in the Gnpat KO group. Furthermore, a shift of the Wenckebach point to longer cycle lengths indicated depressed atrioventricular nodal function. To complement our findings in mice, we analyzed medical records and performed electrocardiography in ether-lipid-deficient human patients, which, in contrast to the murine phenotype, indicated a trend towards shortened QT intervals. Taken together, our findings demonstrate that the cardiac phenotype upon ether lipid deficiency is highly heterogeneous, and although the manifestations in the mouse model only partially match the abnormalities in human patients, the results add to our understanding of the physiological role of ether lipids and emphasize their importance for proper cardiac development and function.
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Affiliation(s)
- Fabian Dorninger
- Department of Pathobiology of the Nervous System, Center for Brain Research, Medical University of Vienna, Spitalgasse 4, 1090 Vienna, Austria
| | - Attila Kiss
- Center for Biomedical Research, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Peter Rothauer
- Department of Neurophysiology and Neuropharmacology, Center for Physiology and Pharmacology, Medical University of Vienna, Währingerstrasse 13a, 1090 Vienna, Austria
| | - Alexander Stiglbauer-Tscholakoff
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Molecular and Structural Preclinical Imaging, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Stefan Kummer
- Neuromuscular Research Department, Center for Anatomy and Cell Biology, Medical University of Vienna, Währinger Straße 13, 1090 Vienna, Austria
| | - Wedad Fallatah
- Department of Genetic Medicine, King AbdulAziz University, Jeddah 21589, Saudi Arabia
- Department of Human Genetics and Pediatrics, Montreal Children’s Hospital, McGill University, 1001 Décarie Blvd, Montreal, QC H4A 3J1, Canada
| | - Mireia Perera-Gonzalez
- Center for Biomedical Research, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Ouafa Hamza
- Center for Biomedical Research, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Theresa König
- Department of Pathobiology of the Nervous System, Center for Brain Research, Medical University of Vienna, Spitalgasse 4, 1090 Vienna, Austria
| | - Michael B. Bober
- Skeletal Dysplasia Program, Nemours Children’s Hospital, 1600 Rockland Road, Wilmington, DE 19803, USA
| | - Tiscar Cavallé-Garrido
- Department of Pediatrics, Division of Cardiology, Montreal Children’s Hospital, McGill University, 1001 Décarie Blvd, Montreal, QC H4A 3J1, Canada
| | - Nancy E. Braverman
- Department of Human Genetics and Pediatrics, Montreal Children’s Hospital, McGill University, 1001 Décarie Blvd, Montreal, QC H4A 3J1, Canada
| | - Sonja Forss-Petter
- Department of Pathobiology of the Nervous System, Center for Brain Research, Medical University of Vienna, Spitalgasse 4, 1090 Vienna, Austria
| | - Christian Pifl
- Department of Molecular Neurosciences, Center for Brain Research, Medical University of Vienna, Spitalgasse 4, 1090 Vienna, Austria
| | - Jan Bauer
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Spitalgasse 4, 1090 Vienna, Austria
| | - Reginald E. Bittner
- Neuromuscular Research Department, Center for Anatomy and Cell Biology, Medical University of Vienna, Währinger Straße 13, 1090 Vienna, Austria
| | - Thomas H. Helbich
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Molecular and Structural Preclinical Imaging, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Bruno K. Podesser
- Center for Biomedical Research, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Hannes Todt
- Department of Neurophysiology and Neuropharmacology, Center for Physiology and Pharmacology, Medical University of Vienna, Währingerstrasse 13a, 1090 Vienna, Austria
| | - Johannes Berger
- Department of Pathobiology of the Nervous System, Center for Brain Research, Medical University of Vienna, Spitalgasse 4, 1090 Vienna, Austria
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17
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Jacquet-Lagrèze M, Ruste M, Fornier W, Jacquemet PL, Schweizer R, Fellahi JL. Refilling and preload dependence failed to predict cardiac index decrease during fluid removal with continuous renal replacement therapy. J Nephrol 2023; 36:187-197. [PMID: 36121642 DOI: 10.1007/s40620-022-01407-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/14/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fluid removal can reduce the burden of fluid overload after initial resuscitation. According to the Frank-Starling model, iatrogenic hypovolemia should induce a decrease in cardiac index. We hypothesized that inadequate refilling detected by haemoconcentration during fluid removal or an increase in cardiac index (CI) during passive leg raising (PLR) could predict CI decrease during mechanical fluid removal with continuous renal replacement therapy (CRRT). METHODS We conducted a single-centre prospective diagnostic accuracy study. The primary objective was to investigate the diagnostic performance of plasma protein concentration variations in detecting a CI decrease ≥ 12% during mechanical fluid removal. Secondary objective was to assess other predictive factors of CI change. The attending physician prescribed a fluid removal challenge consisting of a mechanical fluid removal challenge of 500 mL for one hour. Plasma protein concentration, haemoglobin level, PLR and transpulmonary thermodilution were done before and after the fluid removal challenge. RESULTS We included 69 adult patients between December 2016 and April 2020. Sixteen patients had a significant CI decrease (23% [95% CI 14-35]). Haemoconcentration and PLR before fluid removal challenge or CI trending failed to predict CI decrease. CONCLUSION Haemoconcentration variables, preload dependence status and CI trending failed to predict CI decrease during fluid removal challenge.
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Affiliation(s)
- Matthias Jacquet-Lagrèze
- Department of Anesthesiology and Intensive Care, University Hospital Louis Pradel, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500, Lyon, France. .,Faculty of Medicine Lyon-Est, University Claude Bernard Lyon 1, 69373, Lyon, France. .,Laboratoire CarMeN, Inserm UMR 1060, University Claude Bernard Lyon 1, Lyon, France.
| | - Martin Ruste
- Department of Anesthesiology and Intensive Care, University Hospital Louis Pradel, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500, Lyon, France.,Faculty of Medicine Lyon-Est, University Claude Bernard Lyon 1, 69373, Lyon, France
| | - William Fornier
- Department of Anesthesiology and Intensive Care, University Hospital Louis Pradel, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500, Lyon, France
| | - Pierre-Louis Jacquemet
- Department of Anesthesiology and Intensive Care, University Hospital Louis Pradel, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500, Lyon, France
| | - Remi Schweizer
- Department of Anesthesiology and Intensive Care, University Hospital Louis Pradel, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500, Lyon, France
| | - Jean-Luc Fellahi
- Department of Anesthesiology and Intensive Care, University Hospital Louis Pradel, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500, Lyon, France.,Faculty of Medicine Lyon-Est, University Claude Bernard Lyon 1, 69373, Lyon, France.,Laboratoire CarMeN, Inserm UMR 1060, University Claude Bernard Lyon 1, Lyon, France
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18
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Messina A, Calabrò L, Pugliese L, Lulja A, Sopuch A, Rosalba D, Morenghi E, Hernandez G, Monnet X, Cecconi M. Fluid challenge in critically ill patients receiving haemodynamic monitoring: a systematic review and comparison of two decades. Crit Care 2022; 26:186. [PMID: 35729632 PMCID: PMC9210670 DOI: 10.1186/s13054-022-04056-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/07/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Introduction
Fluid challenges are widely adopted in critically ill patients to reverse haemodynamic instability. We reviewed the literature to appraise fluid challenge characteristics in intensive care unit (ICU) patients receiving haemodynamic monitoring and considered two decades: 2000–2010 and 2011–2021.
Methods
We assessed research studies and collected data regarding study setting, patient population, fluid challenge characteristics, and monitoring. MEDLINE, Embase, and Cochrane search engines were used. A fluid challenge was defined as an infusion of a definite quantity of fluid (expressed as a volume in mL or ml/kg) in a fixed time (expressed in minutes), whose outcome was defined as a change in predefined haemodynamic variables above a predetermined threshold.
Results
We included 124 studies, 32 (25.8%) published in 2000–2010 and 92 (74.2%) in 2011–2021, overall enrolling 6,086 patients, who presented sepsis/septic shock in 50.6% of cases. The fluid challenge usually consisted of 500 mL (76.6%) of crystalloids (56.6%) infused with a rate of 25 mL/min. Fluid responsiveness was usually defined by a cardiac output/index (CO/CI) increase ≥ 15% (70.9%). The infusion time was quicker (15 min vs 30 min), and crystalloids were more frequent in the 2011–2021 compared to the 2000–2010 period.
Conclusions
In the literature, fluid challenges are usually performed by infusing 500 mL of crystalloids bolus in less than 20 min. A positive fluid challenge response, reported in 52% of ICU patients, is generally defined by a CO/CI increase ≥ 15%. Compared to the 2000–2010 decade, in 2011–2021 the infusion time of the fluid challenge was shorter, and crystalloids were more frequently used.
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YILDIZ GÖ, SERTCAKACİLAR G, AKYOL D, KARAKAŞ S, HERGÜNSEL GO. Malign asitli over kanserinde sitoredüktif cerrahide perioperatif hemodinamik optimizasyon. CUKUROVA MEDICAL JOURNAL 2022. [DOI: 10.17826/cumj.1097476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Purpose: In this study, we aimed to evaluate the effects of norepinephrine and albumin use in patients with epithelial ovarian cancer with malignant ascite in order to maintain plasma oncotic pressure and intravascular volume, to provide perioperative hemodynamic stabilization and tissue perfusion. In addition, it was aimed to compare in terms of postoperative intensive care admission, hospital stay and complications.
Materials and Methods: A total of 66 patients, 38 with ascites and 28 without ascites, who underwent cytoreductive surgery for ovarian cancer were included in this study. PVI and invasive arterial monitoring of the patients were performed after hemodynamic stabilization (after the start of surgery) (T0). T0, 1st hour (T1) and 2nd hour (T2) and postoperative (Tpostop.) Ascites patients were composed of 3 subgroups which the ones received norepinephrine (NE) infusion, norepinephrine + albumin (NEA) infusion or only fluid therapy (FT). From the perioperative hemodynamic and laboratory data of the patients, tissue perfusion was evaluated with lactate, and hemodynamic status was evaluated with pleth variability index (PVI), perfusion index (PI) and mean arterial pressure (MAP).
Results: Demographic and clinical findings did not differ significantly between patients with and without ascites. Lactate level in NEA / NE group in Tpostop, PVI level in T1h, T2h and Tpostop time frames were determined higher than the FT group. PI was found to be significantly lower in the T2 time frame. The postoperative ICU admission rate was higher in the NEA and NE groups. The duration of ICU stay in group NEA was shorter than in group NE.
Conclusion: We recommend the use of low-dose NE with albumin to provide perioperative hemodynamic optimization, tissue perfusion and plasma oncotic pressure in surgery of ovarian cancer with malignant ascites. Despite high fluid replacement in these patients, the use of norepinephrine and albumin together may have an important role in preventing / reducing major complications in the perioperative period.
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Affiliation(s)
- Güneş Özlem YILDIZ
- Department of Anesthesiology and Intensive Care, University of Health Sciences Istanbul, Bakirkoy Dr. Sadi Konuk Training and Research Hospital
| | - Gokhan SERTCAKACİLAR
- UNIVERSITY OF HEALTH SCIENCES, İSTANBUL BAKIRKÖY DR. SADİ KONUK TRAINING RESEARCH CENTER
| | - Duygu AKYOL
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, İSTANBUL BAŞAKŞEHİR ÇAM VE SAKURA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ
| | - Sema KARAKAŞ
- UNIVERSITY OF HEALTH SCIENCES, İSTANBUL BAKIRKÖY DR. SADİ KONUK TRAINING RESEARCH CENTER
| | - Gülsüm Oya HERGÜNSEL
- UNIVERSITY OF HEALTH SCIENCES, İSTANBUL BAKIRKÖY DR. SADİ KONUK TRAINING RESEARCH CENTER
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20
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Desebbe O, Mondor W, Gergele L, Raphael D, Vallier S. Variations of pulse pressure and central venous pressure may predict fluid responsiveness in mechanically ventilated patients during lung recruitment manoeuvre: an ancillary study. BMC Anesthesiol 2022; 22:269. [PMID: 35999508 PMCID: PMC9396758 DOI: 10.1186/s12871-022-01815-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/16/2022] [Indexed: 11/10/2022] Open
Abstract
Background Maintaining a constant driving pressure during a prolonged sigh breath lung recruitment manoeuvre (LRM) from 20 to 45 cmH20 peak inspiratory pressure in mechanically ventilated patients has been shown to be a functional test to predict fluid responsiveness (FR) when using a linear regression model of hemodynamic parameters, such as central venous pressure (CVP) and pulse pressure (PP). However, two important limitations have been raised, the use of high ventilation pressures and a regression slope calculation that is difficult to apply at bedside. This ancillary study aimed to reanalyse absolute variations of CVP (ΔCVP) and PP (ΔPP) values at lower stages of the LRM, (40, 35, and 30 cm H20 of peak inspiratory pressure) for their ability to predict fluid responsiveness. Methods Retrospective analysis of a prospective study data set in 18 mechanically ventilated patients, in an intensive care unit. CVP, systemic arterial pressure parameters and stroke volume (SV) were recorded during prolonged LRM followed by a 500 mL crystalloid volume expansion. Patients were considered as fluid responders if SV increased more than 10%. Receiver-operating curves (ROC) analysis with the corresponding grey zone approach were performed. Results Areas under the ROC to predict fluid responsiveness for ΔCVP and ΔPP were not different between the successive stepwise increase of inspiratory pressures [0.88 and 0.89 for ΔCVP at 45 and 30 cm H20 (P = 0.89), respectively, and 0.92 and 0.95 for ΔPP at 45 and 30 cm H20, respectively (P = 0.51)]. Using a maximum of 30 cmH2O inspiratory pressure during the LRM, ΔCVP and ΔPP had a threshold value to predict fluid responsiveness of 2 mmHg and 4 mmHg, with sensitivities of 89% and 89% and specificities of 67% and 89%, respectively. Combining ΔPP and ΔCVP decreased the proportion of the patients in the grey zone from 28 to 11% and showed a sensitivity of 88% and a specificity of 83%. Conclusions A stepwise PEEP elevation recruitment manoeuvre of up to 30 cm H20 may predict fluid responsiveness as well as 45 cm H20. The combination of ΔPP and ΔCVP optimizes the categorization of responder and non-responder patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01815-1.
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Affiliation(s)
- Olivier Desebbe
- Department of Anesthesiology and Intensive Care, Ramsay Sante Sauvegarde Clinic, Lyon, France.
| | - Whitney Mondor
- Department of Biosciences, Claude Bernard University, Lyon, France
| | - Laurent Gergele
- Department of Anesthesiology and Intensive Care, Ramsay Sante HPL Clinic, Saint-Etienne, France
| | - Darren Raphael
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, USA
| | - Sylvain Vallier
- Department of Anesthesiology and Intensive Care, Elsan Alpes-Belledonne Clinic, Grenoble, France
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21
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Jozwiak M. Alternatives to norepinephrine in septic shock: Which agents and when? JOURNAL OF INTENSIVE MEDICINE 2022; 2:223-232. [PMID: 36788938 PMCID: PMC9924015 DOI: 10.1016/j.jointm.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/28/2022] [Accepted: 05/07/2022] [Indexed: 10/18/2022]
Abstract
Vasopressors are the cornerstone of hemodynamic management in patients with septic shock. Norepinephrine is currently recommended as the first-line vasopressor in these patients. In addition to norepinephrine, there are many other potent vasopressors with specific properties and/or advantages that act on vessels through different pathways after activation of specific receptors; these could be of interest in patients with septic shock. Dopamine is no longer recommended in patients with septic shock because its use is associated with a higher rate of cardiac arrhythmias without any benefit in terms of mortality or organ dysfunction. Epinephrine is currently considered as a second-line vasopressor therapy, because of the higher rate of associated metabolic and cardiac adverse effects compared with norepinephrine; however, it may be considered in settings where norepinephrine is unavailable or in patients with refractory septic shock and myocardial dysfunction. Owing to its potential effects on mortality and renal function and its norepinephrine-sparing effect, vasopressin is recommended as second-line vasopressor therapy instead of norepinephrine dose escalation in patients with septic shock and persistent arterial hypotension. However, two synthetic analogs of vasopressin, namely, terlipressin and selepressin, have not yet been employed in the management of patients with septic shock, as their use is associated with a higher rate of digital ischemia. Finally, angiotensin Ⅱ also appears to be a promising vasopressor in patients with septic shock, especially in the most severe cases and/or in patients with acute kidney injury requiring renal replacement therapy. Nevertheless, due to limited evidence and concerns regarding safety (which remains unclear because of potential adverse effects related to its marked vasopressor activity), angiotensin Ⅱ is currently not recommended in patients with septic shock. Further studies are needed to better define the role of these vasopressors in the management of these patients.
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Affiliation(s)
- Mathieu Jozwiak
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire l'Archet 1, 151 route Saint Antoine de Ginestière, 06200 Nice, France,Equipe 2 CARRES UR2CA – Unité de Recherche Clinique Côte d'Azur, Université Côte d'Azur UCA, 06103 Nice, France
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22
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Legrand M, Zarbock A. Ten tips to optimize vasopressors use in the critically ill patient with hypotension. Intensive Care Med 2022; 48:736-739. [PMID: 35504977 DOI: 10.1007/s00134-022-06708-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/16/2022] [Indexed: 01/04/2023]
Affiliation(s)
- Matthieu Legrand
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), 505 Parnassus Avenue, San Francisco, CA, 94143, USA. .,INI-CRCT Network, Nancy, France.
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
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23
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Persichini R, Lai C, Teboul JL, Adda I, Guérin L, Monnet X. Venous return and mean systemic filling pressure: physiology and clinical applications. Crit Care 2022; 26:150. [PMID: 35610620 PMCID: PMC9128096 DOI: 10.1186/s13054-022-04024-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 05/17/2022] [Indexed: 01/15/2023] Open
Abstract
Venous return is the flow of blood from the systemic venous network towards the right heart. At steady state, venous return equals cardiac output, as the venous and arterial systems operate in series. However, unlike the arterial one, the venous network is a capacitive system with a high compliance. It includes a part of unstressed blood, which is a reservoir that can be recruited via sympathetic endogenous or exogenous stimulation. Guyton’s model describes the three determinants of venous return: the mean systemic filling pressure, the right atrial pressure and the resistance to venous return. Recently, new methods have been developed to explore such determinants at the bedside. In this narrative review, after a reminder about Guyton’s model and current methods used to investigate it, we emphasize how Guyton’s physiology helps understand the effects on cardiac output of common treatments used in critically ill patients.
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Affiliation(s)
- Romain Persichini
- Service de Réanimation et Soins Continus, Centre Hospitalier de Saintonge, 11 Boulevard Ambroise Paré, 17108, Saintes cedex, France.
| | - Christopher Lai
- Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France
| | - Jean-Louis Teboul
- Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France
| | - Imane Adda
- Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France
| | - Laurent Guérin
- Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France
| | - Xavier Monnet
- Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France
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24
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Jozwiak M, Geri G, Laghlam D, Boussion K, Dolladille C, Nguyen LS. Vasopressors and Risk of Acute Mesenteric Ischemia: A Worldwide Pharmacovigilance Analysis and Comprehensive Literature Review. Front Med (Lausanne) 2022; 9:826446. [PMID: 35677822 PMCID: PMC9168038 DOI: 10.3389/fmed.2022.826446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 04/21/2022] [Indexed: 12/03/2022] Open
Abstract
Vasodilatory shock, such as septic shock, requires personalized management which include adequate fluid therapy and vasopressor treatments. While these potent drugs are numerous, they all aim to counterbalance the vasodilatory effects of a systemic inflammatory response syndrome. Their specific receptors include α- and β-adrenergic receptors, arginine-vasopressin receptors, angiotensin II receptors and dopamine receptors. Consequently, these may be associated with severe adverse effects, including acute mesenteric ischemia (AMI). As the risk of AMI depends on drug class, we aimed to review the evidence of plausible associations by performing a worldwide pharmacovigilance analysis based on the World Health Organization database, VigiBase®. Among 24 million reports, 104 AMI events were reported, and disproportionality analyses yielded significant association with all vasopressors, to the exception of selepressin. Furthermore, in a comprehensive literature review, we detailed mechanistic phenomena which may enhance vasopressor selection, in the course of treating vasodilatory shock.
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Affiliation(s)
- Mathieu Jozwiak
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire l'Archet 1, Nice, France
- Equipe 2 CARRES UR2CA—Unité de Recherche Clinique Côte d'Azur, Université Côte d'Azur UCA, Nice, France
| | - Guillaume Geri
- Service de Médecine Intensive Réanimation, Centre Médico-Chirurgical Ambroise Paré, Neuilly-sur-Seine, France
| | - Driss Laghlam
- Service de Médecine Intensive Réanimation, Centre Médico-Chirurgical Ambroise Paré, Neuilly-sur-Seine, France
- Faculté de Médecine, Université de Paris, Paris, France
| | - Kevin Boussion
- Service de Médecine Intensive Réanimation, Centre Médico-Chirurgical Ambroise Paré, Neuilly-sur-Seine, France
| | | | - Lee S. Nguyen
- Service de Médecine Intensive Réanimation, Centre Médico-Chirurgical Ambroise Paré, Neuilly-sur-Seine, France
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25
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Yildiz GO, Hergunsel GO, Sertcakacilar G, Akyol D, Karakaş S, Cukurova Z. Perioperative goal-directed fluid management using noninvasive hemodynamic monitoring in gynecologic oncology. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2022; 72:322-330. [PMID: 35121063 PMCID: PMC9373248 DOI: 10.1016/j.bjane.2021.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 12/20/2021] [Accepted: 12/26/2021] [Indexed: 11/29/2022]
Abstract
Background Intraoperative fluid management is important for the prevention of perioperative morbidity and mortality. Our study aimed to investigate the perioperative feasibility and benefits of Goal-Directed Fluid Management (GDFM) using noninvasive hemodynamic monitoring in gynecologic oncology patients with acute blood loss and severe fluid loss. We assessed the effects of GDFM on hemodynamics, organ perfusion, complications, and mortality outcomes. Methods This randomized prospective study included 104 patients over the age of 18 years, including 56 patients with endometrial cancer and 48 patients with ovarian cancer who had open surgery. The anesthetic approach was standardized for all patients. We compared the perioperative results of the subjects who were randomized into GDFM (n = 51) and Liberal Fluid Management (LFM) (n = 53) groups using a computer program. Results The median perioperative crystalloid replacement (2000 vs. 2700; p < 0.001) and total volume of fluid (2260 vs. 3200; p < 0.001) were lower in the GDFM group compared to the LFM group. The hemodynamic findings and the HCO3 and lactate levels of the GDFM group did not significantly change perioperatively. The heart rate, mean arterial pressure, and HCO3 levels of the LFM group decreased and serum lactate levels increased perioperatively. The hospitalization rate in ICU (7.8% vs. 28.3%; p = 0.010), rate of patients with comorbidity conditions indicated in ICU (2% vs. 17%; p = 0.024), and rate of complications (17.6% vs. 35.8%; p = 0.047) were lower in the GDFM group compared to the LFM group. Conclusion The amount of intraoperatively administered crystalloid solution and complication rates were significantly lower in gynecologic oncologic surgery patients who received GDFM. Besides, hemodynamic findings, and lactate levels of the GDFM group did not change significantly during the perioperative period.
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Affiliation(s)
- Gunes O Yildiz
- University of Health Sciences Istanbul, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of Anesthesiology and Intensive Care, İstanbul, Turkey.
| | - Gulsum O Hergunsel
- University of Health Sciences Istanbul, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of Anesthesiology and Intensive Care, İstanbul, Turkey
| | - Gokhan Sertcakacilar
- University of Health Sciences Istanbul, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of Anesthesiology and Intensive Care, İstanbul, Turkey
| | - Duygu Akyol
- University of Health Sciences Istanbul, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of Anesthesiology and Intensive Care, İstanbul, Turkey
| | - Sema Karakaş
- University of Health Sciences Istanbul, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of Gynecological Oncology, İstanbul, Turkey
| | - Zafer Cukurova
- University of Health Sciences Istanbul, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of Anesthesiology and Intensive Care, İstanbul, Turkey
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26
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Andrei S, Nguyen M, Abou-Arab O, Bouhemad B, Guinot PG. Arterial Hypotension Following Norepinephrine Decrease in Septic Shock Patients Is Not Related to Preload Dependence: A Prospective, Observational Cohort Study. Front Med (Lausanne) 2022; 9:818386. [PMID: 35273979 PMCID: PMC8901484 DOI: 10.3389/fmed.2022.818386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/24/2022] [Indexed: 11/30/2022] Open
Abstract
Background The optimal management of hypotensive patients during norepinephrine weaning is unclear. The primary study aim was to assess the ability of preload dependence to predict hypotension following norepinephrine weaning. The secondary aims were to describe the effect of norepinephrine weaning on preload dependence, and the cardiovascular effects of fluid expansion in hypotensive patients following norepinephrine weaning. Materials and Methods This was a prospective observational monocentric study. We included PiCCO®-monitored patients with norepinephrine-treated septic shock, for whom the physician decided to decrease the norepinephrine dosage during the de-escalation phase. Three consecutive steps were evaluated with hemodynamic measurements: baseline, after norepinephrine decrease, and after 500 mL fluid expansion. Results Forty-five patients were included. Preload dependence assessed by stroke volume changes following passive leg raising was not predictive of pressure response to norepinephrine weaning [AUC of 0.42 (95%CI: 0.25–0.59, p = 0.395)]. After fluid expansion, there was no difference in the prior preload dependence between pressure-responders and non-pressure-responders (14 vs. 13%, p = 1). The pressure response to norepinephrine decrease was not associated with pressure response after fluid expansion (40 vs. 23%, p = 0.211). Conclusion Hypotension following norepinephrine decrease was not predicted by preload dependence, and there was no association between arterial hypotension after norepinephrine decrease and fluid response.
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Affiliation(s)
- Stefan Andrei
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France.,Anaesthesiology and Intensive Care Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Maxime Nguyen
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France.,University of Burgundy Franche Comté, Dijon, France
| | - Osama Abou-Arab
- Anaesthesiology and Critical Care Department, Amiens Picardie University Hospital, Dijon, France
| | - Belaid Bouhemad
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France.,University of Burgundy Franche Comté, Dijon, France
| | - Pierre-Grégoire Guinot
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France.,University of Burgundy Franche Comté, Dijon, France
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27
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Nugent K, Berdine G, Pena C. Does Fluid Administration Based on Fluid Responsiveness Tests such as Passive Leg Raising Improve Outcomes in Sepsis? Curr Cardiol Rev 2022; 18:18-23. [PMID: 35249497 PMCID: PMC9896423 DOI: 10.2174/1573403x18666220304202556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 01/06/2022] [Accepted: 01/24/2022] [Indexed: 11/22/2022] Open
Abstract
The management of sepsis requires the rapid administration of fluid to support blood pressure and tissue perfusion. Guidelines suggest that patients should receive 30 ml per kg of fluid over the first one to three hours of management. The next concern is to determine which patients need additional fluid. This introduces the concept of fluid responsiveness, defined by an increase in cardiac output following the administration of a fluid bolus. Dynamic tests, measuring cardiac output, identify fluid responders better than static tests. Passive leg raising tests provide an alternative approach to determine fluid responsiveness without administering fluid. However, one small randomized trial demonstrated that patients managed with frequent passive leg raising tests had a smaller net fluid balance at 72 hours and reduced requirements for renal replacement therapy and mechanical ventilation, but no change in mortality. A meta-analysis including 4 randomized control trials reported that resuscitation guided by fluid responsiveness does not improve mortality outcomes in patients with sepsis. Recent studies have demonstrated that the early administration of norepinephrine may improve outcomes in patients with sepsis. The concept of fluid responsiveness helps clinicians analyze the clinical status of patients, but this information must be integrated into the overall management of the patient. This review considers the use and benefit of fluid responsiveness tests to direct fluid administration in patients with sepsis.
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Affiliation(s)
- Kenneth Nugent
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock Texas, USA
| | - Gilbert Berdine
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock Texas, USA
| | - Camilo Pena
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock Texas, USA
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28
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Grand J, Hassager C, Schmidt H, Møller JE, Mølstrøm S, Nyholm B, Kjaergaard J. Hemodynamic evaluation by serial right heart catheterizations after cardiac arrest; protocol of a sub-study from the Blood Pressure and Oxygenation Targets after Out-of-Hospital Cardiac Arrest-trial (BOX). Resusc Plus 2021; 8:100188. [PMID: 34950913 PMCID: PMC8671111 DOI: 10.1016/j.resplu.2021.100188] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/20/2021] [Accepted: 11/22/2021] [Indexed: 01/20/2023] Open
Abstract
Background Neurological injury and mortality remain high in comatose patients resuscitated from out-of-hospital cardiac arrest (OHCA). Hypotension and hypoxia during post-resuscitation care have been associated with poor outcome, but the optimal oxygenation- and blood pressure-targets are unknown. The impact of different doses of norepinephrine on advanced hemodynamic after OHCA and the impact of different oxygenation-targets on pulmonary circulation and resistance (PVR), are unknown. The aims of this substudy of the "Blood pressure and oxygenations targets after out-of-hospital cardiac arrest (BOX)"-trial are to investigate the effect of two different MAP- and oxygenation-targets on advanced systemic and pulmonary hemodynamics measured by pulmonary artery catheters (PAC). Methods The BOX-trial is an investigator-initiated, randomized, controlled study comparing targeted MAP of 63 mmHg vs 77 mmHg (double-blinded intervention) and 9-10 kPa versus PaO2 of 13-14 kPa oxygenation-targets (open-label). Per protocol, all patients will be monitored systematically with PACs. The primary endpoint of the hemodynamic-substudy is cardiac output for the MAP-intervention, and PVR for the oxygenation-intervention. For both endpoints, the difference within 48 h between groups are assessed. Secondary endpoints are pulmonary capillary wedge pressure and pulmonary arterial pressure and association between advanced hemodynamic variables and mortality and biomarkers of inflammation and brain injury. Discussion In the BOX-trial, patients will be randomly allocated to two levels of MAP and oxygenation, which are central parts of post-resuscitation care and where evidence is sparse. The advanced-hemodynamic substudy will give valuable knowledge of the hemodynamic consequences of changing blood pressure and oxygen-levels of the critical cardiac patient. It will be one of the largest clinical, prospective trials of advanced hemodynamics measured by serial PACs in consecutive comatose patients, resuscitated after OHCA. The randomized and placebo-controlled trialdesign of the MAP-intervention minimizes risk of selection bias and confounders. Furthermore, hemodynamic characteristics and associations with outcome will be investigated. Trial registration ClinicalTrials.gov (ClinicalTrials.gov Identifier: NCT03141099). Registered March 30, 2017.
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Affiliation(s)
- Johannes Grand
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Henrik Schmidt
- Department of Anesthesiology and Intensive Care, Odense University Hospital, 5000 Odense C, Denmark
| | - Jacob E Møller
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark.,Department of Cardiology, Odense University Hospital, 5000 C Odense, Denmark
| | - Simon Mølstrøm
- Department of Cardiology, Odense University Hospital, 5000 C Odense, Denmark
| | - Benjamin Nyholm
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
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29
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Beyls C, Hermida A, Bohbot Y, Martin N, Viart C, Boisgard S, Daumin C, Huette P, Dupont H, Abou-Arab O, Mahjoub Y. Automated left atrial strain analysis for predicting atrial fibrillation in severe COVID-19 pneumonia: a prospective study. Ann Intensive Care 2021; 11:168. [PMID: 34874509 PMCID: PMC8649321 DOI: 10.1186/s13613-021-00955-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 11/21/2021] [Indexed: 12/15/2022] Open
Abstract
Background Atrial fibrillation (AF) is the most documented arrhythmia in COVID-19 pneumonia. Left atrial (LA) strain (LAS) analysis, a marker of LA contractility, have been associated with the development of AF in several clinical situations. We aimed to assess the diagnostic ability of LA strain parameters to predict AF in patients with severe hypoxemic COVID-19 pneumonia. We conducted a prospective single center study in Amiens University Hospital intensive care unit (ICU) (France). Adult patients with severe or critical COVID-19 pneumonia according to the World Health Organization definition and in sinus rhythm were included. Transthoracic echocardiography was performed within 48 h of ICU admission. LA strain analysis was performed by an automated software. The following LA strain parameters were recorded: LA strain during reservoir phase (LASr), LA strain during conduit phase (LAScd) and LA strain during contraction phase (LASct). The primary endpoint was the occurrence of AF during ICU stay. Results From March 2020 to February of 2021, 79 patients were included. Sixteen patients (20%) developed AF in ICU. Patients of the AF group were significantly older with a higher SAPS II score than those without AF. LAScd and LASr were significantly more impaired in the AF group compared to the other group (− 8.1 [− 6.3; − 10.9] vs. − 17.2 [− 5.0; − 10.2] %; P < 0.001 and 20.2 [12.3;27.3] % vs. 30.5 [23.8;36.2] %; P = 0.002, respectively), while LASct did not significantly differ between groups (p = 0.31). In a multivariate model, LAScd and SOFA cv were significantly associated with the occurrence of AF. A LAScd cutoff value of − 11% had a sensitivity of 76% and a specificity of 75% to identify patients with AF. The 30-day cumulative risk of AF was 42 ± 9% with LAScd > − 11% and 8 ± 4% with LAScd ≤ − 11% (log rank test P value < 0.0001). Conclusion For patients with severe COVID-19 pneumonia, development of AF during ICU stay is common (20%). LAS parameters seem useful in predicting AF within the first 48 h of ICU admission. Trial registration: NCT04354558.
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Affiliation(s)
- Christophe Beyls
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, 1, Rond-point du Pr Cabrol, 80054, Amiens, Cedex 1, France. .,UR UPJV 7518 SSPC (Simplification of Care of Complex Surgical Patients) Research Unit, University of Picardie Jules Verne, Amiens, France.
| | - Alexis Hermida
- Department of Rythmology, Amiens University Hospital, 80054, Amiens, France
| | - Yohann Bohbot
- Department of Cardiology, Amiens University Hospital, 80054, Amiens, France
| | - Nicolas Martin
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, 1, Rond-point du Pr Cabrol, 80054, Amiens, Cedex 1, France
| | - Christophe Viart
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, 1, Rond-point du Pr Cabrol, 80054, Amiens, Cedex 1, France
| | - Solenne Boisgard
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, 1, Rond-point du Pr Cabrol, 80054, Amiens, Cedex 1, France
| | - Camille Daumin
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, 1, Rond-point du Pr Cabrol, 80054, Amiens, Cedex 1, France
| | - Pierre Huette
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, 1, Rond-point du Pr Cabrol, 80054, Amiens, Cedex 1, France
| | - Hervé Dupont
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, 1, Rond-point du Pr Cabrol, 80054, Amiens, Cedex 1, France
| | - Osama Abou-Arab
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, 1, Rond-point du Pr Cabrol, 80054, Amiens, Cedex 1, France
| | - Yazine Mahjoub
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, 1, Rond-point du Pr Cabrol, 80054, Amiens, Cedex 1, France
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Hamzaoui O. Combining fluids and vasopressors: A magic potion? JOURNAL OF INTENSIVE MEDICINE 2021; 2:3-7. [PMID: 36789229 PMCID: PMC9923992 DOI: 10.1016/j.jointm.2021.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 09/30/2021] [Accepted: 09/30/2021] [Indexed: 11/28/2022]
Abstract
Early detection and prompt reversal of sepsis-induced tissue hypoperfusion are key elements while treating patients with septic shock. Fluid administration is widely accepted as the first-line therapy followed by vasopressor use in persistently hypotensive patients or in those with insufficient arterial pressure to ensure adequate tissue perfusion. Recent evidence suggests a beneficial effect of combining fluids with vasopressors in the early phase of sepsis. Compared with fluids alone, combining fluids and vasopressors increases mean systemic pressure and venous return and corrects hypotension better. This approach also limits fluid overload, which is an independent factor of poor outcomes in sepsis. It produces less hemodilution than fluids alone. As a consequence of these effects, combined treatment may improve outcomes in septic shock patients.
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Cioccari L, Jakob SM, Takala J. Should Vasopressors Be Started Early in Septic Shock? Semin Respir Crit Care Med 2021; 42:683-688. [PMID: 34544185 DOI: 10.1055/s-0041-1733897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Sepsis can influence blood volume, its distribution, vascular tone, and cardiac function. Persistent hypotension or the need for vasopressors after volume resuscitation is part of the definition of septic shock. Since increased positive fluid balance has been associated with increased morbidity and mortality in sepsis, timing of vasopressors in the treatment of septic shock seems crucial. However, conclusive evidence on timing and sequence of interventions with the goal to restore tissue perfusion is lacking. The aim of this narrative review is to depict the pathophysiology of hypotension in sepsis, evaluate how common interventions to treat hypotension interfere with physiology, and to give a resume of the results from clinical studies focusing on targets and timing of vasopressor in sepsis. The majority of studies comparing early versus late administration of vasopressors in septic shock are rather small, single-center, and retrospective. The range of "early" is between 1 and 12 hours. The available studies suggest a mean arterial pressure of 60 to 65 mm Hg as a threshold for increased risk of morbidity and mortality, whereas higher blood pressure targets do not seem to add further benefits. The data, albeit mostly from observational studies, speak for combining vasopressors with fluids rather "early" in the treatment of septic shock (within a 0-3-hour window). Nevertheless, the optimal resuscitation strategy should take into account the source of infection, the pathophysiology, the time and clinical course preceding the diagnosis of sepsis, and also comorbidities and sepsis-induced organ dysfunction.
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Affiliation(s)
- Luca Cioccari
- Department of Intensive Care Medicine, University of Bern, Bern University Hospital, Bern, Switzerland
| | - Stephan M Jakob
- Department of Intensive Care Medicine, University of Bern, Bern University Hospital, Bern, Switzerland
| | - Jukka Takala
- Department of Intensive Care Medicine, University of Bern, Bern University Hospital, Bern, Switzerland
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Nguyen M, Mallat J, Marc J, Abou-Arab O, Bouhemad B, Guinot PG. Arterial Load and Norepinephrine Are Associated With the Response of the Cardiovascular System to Fluid Expansion. Front Physiol 2021; 12:707832. [PMID: 34421648 PMCID: PMC8371483 DOI: 10.3389/fphys.2021.707832] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/09/2021] [Indexed: 12/11/2022] Open
Abstract
Background Fluid responsiveness has been extensively studied by using the preload prism. The arterial load might be a factor modulating the fluid responsiveness. The norepinephrine (NE) administration increases the arterial load and modifies the vascular properties. The objective of the present study was to determine the relationship between fluid responsiveness, preload, arterial load, and NE use. We hypothesized that as a preload/arterial load, NE use may affect fluid responsiveness. Methods The retrospective multicentered analysis of the pooled data from 446 patients monitored using the transpulmonary thermodilution before and after fluid expansion (FE) was performed. FE was standardized between intensive care units (ICUs). The comparison of patients with and without NE at the time of fluid infusion was performed. Stroke volume (SV) responsiveness was defined as an increase of more than 15% of SV following the FE. Pressure responsiveness was defined as an increase of more than 15% of mean arterial pressure (MAP) following the FE. Arterial elastance was used as a surrogate for the arterial load. Results A total of 244 patients were treated with NE and 202 were not treated with NE. By using the univariate analysis, arterial elastance was correlated to SV variations with FE. However, the SV variations were not associated with NE administration (26 [15; 46]% vs. 23 [10; 37]%, p = 0.12). By using the multivariate analysis, high arterial load and NE administration were associated with fluid responsiveness. The association between arterial elastance and fluid responsiveness was less important in patients treated with NE. Arterial compliance increased in the absence of NE, but it did not change in patients treated with NE (6 [−8; 19]% vs. 0 [−13; 15]%, p = 0.03). The changes in total peripheral and arterial elastance were less important in patients treated with NE (−8 [−17; 1]% vs. −11 [−20; 0]%, p < 0.05 and −10 [−19; 0]% vs. −16 [−24; 0]%, p = 0.01). Conclusion The arterial load and NE administration were associated with fluid responsiveness. A high arterial load was associated with fluid responsiveness. In patients treated with NE, this association was lower, and the changes of arterial load following FE seemed to be driven mainly by its resistive component.
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Affiliation(s)
- Maxime Nguyen
- Department of Anesthesiology and Intensive Care, Centre Hospitalier Universitaire, Dijon, France.,Lipness Team, INSERM Research Center LNC-UMR 1231 and LabExLipSTIC, University of Burgundy, Dijon, France
| | - Jihad Mallat
- Department of Anaesthesiology and Intensive Care, Centre Hospitalier, Lens, France
| | - Julien Marc
- Department of Anaesthesiology and Intensive Care, Centre Hospitalier, Lens, France
| | - Osama Abou-Arab
- Department of Anaesthesiology and Intensive Care, Centre Hospitalier Universitaire, Amiens, France
| | - Bélaïd Bouhemad
- Department of Anesthesiology and Intensive Care, Centre Hospitalier Universitaire, Dijon, France.,Lipness Team, INSERM Research Center LNC-UMR 1231 and LabExLipSTIC, University of Burgundy, Dijon, France
| | - Pierre-Grégoire Guinot
- Department of Anesthesiology and Intensive Care, Centre Hospitalier Universitaire, Dijon, France.,Lipness Team, INSERM Research Center LNC-UMR 1231 and LabExLipSTIC, University of Burgundy, Dijon, France
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Adda I, Lai C, Teboul JL, Guerin L, Gavelli F, Monnet X. Norepinephrine potentiates the efficacy of volume expansion on mean systemic pressure in septic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:302. [PMID: 34419120 PMCID: PMC8379760 DOI: 10.1186/s13054-021-03711-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/28/2021] [Indexed: 01/27/2023]
Abstract
Background Through venous contraction, norepinephrine (NE) increases stressed blood volume and mean systemic pressure (Pms) and exerts a “fluid-like” effect. When both fluid and NE are administered, Pms may not only result from the sum of the effects of both drugs. Indeed, norepinephrine may enhance the effects of volume expansion: because fluid dilutes into a more constricted, smaller, venous network, fluid may increase Pms to a larger extent at a higher than at a lower dose of NE. We tested this hypothesis, by mimicking the effects of fluid by passive leg raising (PLR). Methods In 30 septic shock patients, norepinephrine was decreased to reach a predefined target of mean arterial pressure (65–70 mmHg by default, 80–85 mmHg in previously hypertensive patients). We measured the PLR-induced increase in Pms (heart–lung interactions method) under high and low doses of norepinephrine. Preload responsiveness was defined by a PLR-induced increase in cardiac index ≥ 10%. Results Norepinephrine was decreased from 0.32 [0.18–0.62] to 0.26 [0.13–0.50] µg/kg/min (p < 0.0001). This significantly decreased the mean arterial pressure by 10 [7–20]% and Pms by 9 [4–19]%. The increase in Pms (∆Pms) induced by PLR was 13 [9–19]% at the higher dose of norepinephrine and 11 [6–16]% at the lower dose (p < 0.0001). Pms reached during PLR at the high dose of NE was higher than expected by the sum of Pms at baseline at low dose, ∆Pms induced by changing the norepinephrine dose and ∆Pms induced by PLR at low dose of NE (35.6 [11.2] mmHg vs. 33.6 [10.9] mmHg, respectively, p < 0.01). The number of preload responders was 8 (27%) at the high dose of NE and 15 (50%) at the low dose. Conclusions Norepinephrine enhances the Pms increase induced by PLR. These results suggest that a bolus of fluid of the same volume has a greater haemodynamic effect at a high dose than at a low dose of norepinephrine during septic shock. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03711-5.
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Affiliation(s)
- Imane Adda
- AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, 78, Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.
| | - Christopher Lai
- AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, 78, Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Jean-Louis Teboul
- AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, 78, Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Laurent Guerin
- AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, 78, Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Francesco Gavelli
- AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, 78, Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Xavier Monnet
- AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, 78, Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
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Guinot PG, Martin A, Berthoud V, Voizeux P, Bartamian L, Santangelo E, Bouhemad B, Nguyen M. Vasopressor-Sparing Strategies in Patients with Shock: A Scoping-Review and an Evidence-Based Strategy Proposition. J Clin Med 2021; 10:3164. [PMID: 34300330 PMCID: PMC8306396 DOI: 10.3390/jcm10143164] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 01/15/2023] Open
Abstract
Despite the abundant literature on vasopressor therapy, few studies have focused on vasopressor-sparing strategies in patients with shock. We performed a scoping-review of the published studies evaluating vasopressor-sparing strategies by analyzing the results from randomized controlled trials conducted in patients with shock, with a focus on vasopressor doses and/or duration reduction. We analyzed 143 studies, mainly performed in septic shock. Our analysis demonstrated that several pharmacological and non-pharmacological strategies are associated with a decrease in the duration of vasopressor therapy. These strategies are as follows: implementing a weaning strategy, vasopressin use, systemic glucocorticoid administration, beta-blockers, and normothermia. On the contrary, early goal directed therapies, including fluid therapy, oral vasopressors, vitamin C, and renal replacement therapy, are not associated with an increase in vasopressor-free days. Based on these results, we proposed an evidence-based vasopressor management strategy.
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Affiliation(s)
- Pierre-Grégoire Guinot
- Department of Anesthesiology and Intensive Care, CHU Dijon, 21000 Dijon, France; (A.M.); (V.B.); (P.V.); (L.B.); (E.S.); (B.B.); (M.N.)
- Lipness Team, INSERM Research Center LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, 21000 Dijon, France
| | - Audrey Martin
- Department of Anesthesiology and Intensive Care, CHU Dijon, 21000 Dijon, France; (A.M.); (V.B.); (P.V.); (L.B.); (E.S.); (B.B.); (M.N.)
| | - Vivien Berthoud
- Department of Anesthesiology and Intensive Care, CHU Dijon, 21000 Dijon, France; (A.M.); (V.B.); (P.V.); (L.B.); (E.S.); (B.B.); (M.N.)
| | - Pierre Voizeux
- Department of Anesthesiology and Intensive Care, CHU Dijon, 21000 Dijon, France; (A.M.); (V.B.); (P.V.); (L.B.); (E.S.); (B.B.); (M.N.)
| | - Loic Bartamian
- Department of Anesthesiology and Intensive Care, CHU Dijon, 21000 Dijon, France; (A.M.); (V.B.); (P.V.); (L.B.); (E.S.); (B.B.); (M.N.)
| | - Erminio Santangelo
- Department of Anesthesiology and Intensive Care, CHU Dijon, 21000 Dijon, France; (A.M.); (V.B.); (P.V.); (L.B.); (E.S.); (B.B.); (M.N.)
| | - Belaid Bouhemad
- Department of Anesthesiology and Intensive Care, CHU Dijon, 21000 Dijon, France; (A.M.); (V.B.); (P.V.); (L.B.); (E.S.); (B.B.); (M.N.)
- Lipness Team, INSERM Research Center LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, 21000 Dijon, France
| | - Maxime Nguyen
- Department of Anesthesiology and Intensive Care, CHU Dijon, 21000 Dijon, France; (A.M.); (V.B.); (P.V.); (L.B.); (E.S.); (B.B.); (M.N.)
- Lipness Team, INSERM Research Center LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, 21000 Dijon, France
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The Effect of Changing Arterial Transducer Position on Stroke Volume Measurements Using FloTrac System Version 4.0: A Pilot Experimental Study. Crit Care Explor 2021; 3:e0465. [PMID: 34151286 PMCID: PMC8208422 DOI: 10.1097/cce.0000000000000465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. Objectives: We conducted a pilot study using an experimental study protocol to evaluate the measurement error of arterial pulse contour analysis-derived stroke volume due to improper transducer leveling during the passive leg raising test and the impact of such error on the determination of fluid responsiveness. Design: Prospective observational study. Setting: A medical-surgical ICU at a tertiary referral center in Kobe, Japan. Patients: Consecutive critically ill adult patients using the FloTrac system Version 4.0 (Edwards Lifesciences, Irvine, CA) for hemodynamic monitoring between September 1, 2018, and November 31, 2018. Interventions: None. Measurements and Main Results: Using 20 patients, we estimated the change in the zero-reference level of an arterial transducer during head-down tilting as the vertical distance between the zero-reference levels of the transducer in the 45° semi-recumbent and supine positions. Using the FloTrac system Version 4.0, we recorded the hemodynamic variables every 20 seconds for 180 seconds at each of the following three points: 1) baseline, 2) after the transducer was elevated by the predetermined distance, and 3) after the transducer had returned to baseline. With respect to the predetermined change in the transducer level, a mean value of 18 ± 3 cm resulted in an increase in stroke volume measurement (mean value, 11 mL/beat; 95% CI, 10–13). This value corresponded to 20% (95% CI, 18–23%) of the baseline value 20 seconds after changing the transducer level. A significant correlation was observed between the predetermined change in the transducer level and the increase in the measured stroke volume (r2 = 0.58; p < 0.001). CONCLUSIONS: When using the FloTrac system Version 4.0, a rapid increase in stroke volume was observed after elevating the arterial transducer. Clinicians and researchers are advised that proper leveling of the arterial transducer is necessary in order to accurately assess the change in arterial pulse contour analysis-derived stroke volume during the passive leg raising test.
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He H, Yuan S, Long Y, Liu D, Zhou X, Ince C. Effect of norepinephrine challenge on cardiovascular determinants assessed using a mathematical model in septic shock: a physiological study. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:561. [PMID: 33987259 PMCID: PMC8105783 DOI: 10.21037/atm-20-6686] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/12/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND The present study investigated the cardiovascular determinants of cardiac output (CO), mean systemic filling pressure analogue (Pmsa) derived by Geoffrey Parkin, efficiency of heart (Eh) and related parameters to a norepinephrine (NE) challenge [an increase of 10 mmHg mean arterial pressure (MAP) by NE] in septic shock patients using of a mathematical model. METHODS Twenty-seven septic shock patients with pulse index continuous cardiac output (PiCCO) monitoring were enrolled. These patients required NE to maintain an individualized MAP for organ perfusion after early fluid resuscitation based on their clinical condition. NE was decreased to obtain a decrease of 10 mmHg from base MAP (MAP-10mmHg), and the NE doses were adjusted to return MAP to baseline (MAPbase) and produce an increase of 10 mmHg from MAPbase (MAP+10mmHg). Two NE challenge episodes were analyzed for each patient: from MAP-10mmHg to MAPbase and from MAPbase to MAP+10mmHg. The Pmsa, pressure gradient for venous return (PGvr), and Eh (PGvr relative to Pmsa) were estimated using a mathematical model for the three MAP levels (MAP-10mmHg, MAPbase and MAP+10mmHg). RESULTS A total of 54 episodes of NE challenges were obtained in 27 patients. Significant and consistent increases were observed in the central venous pressure (CVP), Pmsa, and PGvr in response during the NE titration. ΔCO negatively and significantly correlated with ΔCVP (r=-0.722, P<0.0001), ΔPmsa (r=-0.549, P<0.0001), ΔResistance of venous return (Rvr) (r=-0.597, P<0.0001), and ΔResistance of systemic vascular beds (Rsys) (r=-0.597, P<0.0001). Episodes of decreasing CO/Eh were associated with a higher ΔCVP than the CO/Eh-increasing episodes. The area under the curve (AUC) of ΔCVP to predict decreased CO by the incremental NE was 0.86, and the AUC of ΔCVP to predict decreased Eh was 0.94. A cutoff of ΔCVP >1.5 mmHg for detecting decreased CO resulted in a sensitivity of 75% and a specificity of 94.1%. A cutoff of ΔCVP >1.5 mmHg for detecting decreased Eh resulted in a sensitivity of 64.3% and a specificity of 100%. CONCLUSIONS There were a highly divergent response in Eh and CO to afterload challenge episodes of an NE-induced 10mmHg increase in MAP. An increase in CVP may be an early alarm to identify the reduction in CO/Eh during an NE-induced increase of MAP.
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Affiliation(s)
- Huaiwu He
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Siyi Yuan
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Dawei Liu
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Xiang Zhou
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Can Ince
- Department of Intensive Care, Erasmus MC University Hospital, Rotterdam, The Netherlands
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Vasopressor Responsiveness Beyond Arterial Pressure: A Conceptual Systematic Review Using Venous Return Physiology. Shock 2021; 56:352-359. [PMID: 33756500 DOI: 10.1097/shk.0000000000001762] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT We performed a systematic review to investigate the effects of vasopressor-induced hemodynamic changes in adults with shock. We applied a physiological approach using the interacting domains of intravascular volume, heart pump performance, and vascular resistance to structure the interpretation of responses to vasopressors. We hypothesized that incorporating changes in determinants of cardiac output and vascular resistance better reflect the vasopressor responsiveness beyond mean arterial pressure alone.We identified 28 studies including 678 subjects in Pubmed, EMBASE, and CENTRAL databases.All studies demonstrated significant increases in mean arterial pressure (MAP) and systemic vascular resistance during vasopressor infusion. The calculated mean systemic filling pressure analogue increased (16 ± 3.3 mmHg to 18 ± 3.4 mmHg; P = 0.02) by vasopressors with variable effects on central venous pressure and the pump efficiency of the heart leading to heterogenous changes in cardiac output. Changes in the pressure gradient for venous return and cardiac output, scaled by the change in MAP, were positively correlated (r2 = 0.88, P < 0.001). Changes in the mean systemic filling pressure analogue and heart pump efficiency were negatively correlated (r2 = 0.57, P < 0.001) while no correlation was found between changes in MAP and heart pump efficiency.We conclude that hemodynamic changes induced by vasopressor therapy are inadequately represented by the change in MAP alone despite its common use as a clinical endpoint. The more comprehensive analysis applied in this review illustrates how vasopressor administration may be optimized.
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Kenny JES, Barjaktarevic I. Letter to the Editor: Stroke volume is the key measure of fluid responsiveness. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:104. [PMID: 33722261 PMCID: PMC7962206 DOI: 10.1186/s13054-021-03498-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 02/08/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Jon-Emile S Kenny
- Health Sciences North Research Institute, 56 Walford Rd, Sudbury, ON, P3E 2H2, Canada.
| | - Igor Barjaktarevic
- Division of Pulmonary and Critical Care, Department of Medicine, David Geffen School of Medicine At UCLA, Los Angeles, CA, USA
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Bolus norepinephrine and phenylephrine for maternal hypotension during elective cesarean section with spinal anesthesia: a randomized, double-blinded study. Chin Med J (Engl) 2020; 133:509-516. [PMID: 31996543 PMCID: PMC7065858 DOI: 10.1097/cm9.0000000000000621] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In recent years, norepinephrine has attracted increasing attention for the management of maternal hypotension during elective cesarean section with spinal anesthesia. Intermittent bolus is a widely used administration paradigm for vasopressors in obstetric anesthesia in China. Thus, in this randomized, double-blinded study, we compared the efficacy and safety of equivalent bolus norepinephrine and phenylephrine for rescuing maternal post-spinal hypotension. METHODS In a tertiary women's hospital in Nanjing, China, 102 women were allocated with computer derived randomized number to receive prophylactic 8 μg norepinephrine (group N; n = 52) or 100 μg phenylephrine (group P; n = 50) immediately post-spinal anesthesia, followed by an extra bolus of the same dosage until delivery whenever maternal systolic blood pressure became lower than 80% of the baseline. Our primary outcome was standardized maternal cardiac output (CO) reading from spinal anesthesia until delivery analyzed by a two-step method. Other hemodynamic parameters related to vasopressor efficacy and safety were considered as secondary outcomes. Maternal side effects and neonatal outcomes were collected as well. RESULTS Compared to group P, women in group N had a higher CO (standardized CO 5.8 ± 0.9 vs. 5.3 ± 1.0 L/min, t = 2.37, P = 0.02) and stroke volume (SV, standardized SV 73.6 ± 17.2 vs. 60.0 ± 13.3 mL, t = 4.52, P < 0.001), and a lower total peripheral resistance (875 ± 174 vs. 996 ± 182 dyne·s/cm, t = 3.44, P < 0.001). Furthermore, the incidence of bradycardia was lower in group N than in group P (2% vs. 14%, P = 0.023), along with an overall higher standardized heart rate (78.8 ± 11.6 vs. 75.0 ± 7.3 beats/min, P = 0.049). Other hemodynamics, as well as maternal side effects and neonatal outcomes, were similar in two groups (P > 0.05). CONCLUSIONS Compared to equivalent phenylephrine, intermittent bolus norepinephrine provides a greater CO for management of maternal hypotension during elective cesarean section with spinal anesthesia; however, no obvious maternal or neonatal clinical advantages were observed for norepinephrine.
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Hu B, Xiang H, Dong Y, Portner E, Peng Z, Kashani K. Timeline of sepsis bundle component completion and its association with septic shock outcomes. J Crit Care 2020; 60:143-151. [PMID: 32805593 DOI: 10.1016/j.jcrc.2020.07.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 07/14/2020] [Accepted: 07/26/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE To assess the impact of the timeline of sepsis bundle completion with clinical outcomes in septic shock. MATERIALS AND METHODS We retrospectively studied adult (≥18 years) patients with septic shock from January 1, 2006, through May 31, 2018, who were admitted to the intensive care unit in Mayo Clinic, Rochester. We divided patients into three groups based on the SSC compliant 1) <1h, 2) 1.1 to 3 h, 3) >3 h after the time of septic shock diagnosis. RESULTS We enrolled 1052 septic shock patients, among 8% were in group 1, 26% in group 2, and the remaining in group 3. Those who completed all bundle components within 3 h had the lowest 28-day mortality (17.5% vs. 31.4%, p < .001) and higher survival at 90 days (HR = 0.67; 95% CI 0.55-0.80; p < .001). Sepsis bundle completion in <1 h had no significant advantage in 28-day mortality (21.5% vs.15.9%, p = .4) or 90-day survival compared with group 2 (HR = 1.08; 95% CI 0.77-1.53; p = .6). CONCLUSIONS We showed an association between the completion of SSC bundle components within three hours with lower mortality or earlier shock reversal. This relationship was not evident when compared to bundle completion in 1 h vs. within 3 h.
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Affiliation(s)
- Bo Hu
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, United States of America; Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Hui Xiang
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Yue Dong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Erica Portner
- Department of Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, MN, United States of America
| | - Zhiyong Peng
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China.
| | - Kianoush Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, United States of America; Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, United States of America.
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Haas A, Schürholz T, Reuter DA. [Perioperative pharmacological circulatory support in daily clinical routine]. Anaesthesist 2020; 69:781-792. [PMID: 32572502 DOI: 10.1007/s00101-020-00803-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Perioperative phases of hypotension are associated with an increase in postoperative complications and organ damage. Whereas some years ago hemodynamic stabilization was primarily carried out by volume supplementation, in recent years the use and dosing of cardiovascular-active substances has significantly increased. But like intravascular volume therapy, also substances with a cardiovascular effect have therapeutic margins, and thus, potential side effects. This review article discusses indications for each cardiovascular-active agent, weighing up advantages and disadvantages. Special attention is paid to the question how to administrate them: central venous catheter vs. peripheral indwelling venous cannula. The authors come to the conclusion that it is not a question of whether it is principally allowed to apply cardiovascular-active drugs via peripheral veins but more importantly, what should be taken into consideration if a peripheral venous access is used. This article provides concise recommendations.
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Affiliation(s)
- A Haas
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland
| | - T Schürholz
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland
| | - D A Reuter
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland.
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Jones TW, Smith SE, Van Tuyl JS, Newsome AS. Sepsis With Preexisting Heart Failure: Management of Confounding Clinical Features. J Intensive Care Med 2020; 36:989-1012. [PMID: 32495686 DOI: 10.1177/0885066620928299] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Preexisting heart failure (HF) in patients with sepsis is associated with worse clinical outcomes. Core sepsis management includes aggressive volume resuscitation followed by vasopressors (and potentially inotropes) if fluid is inadequate to restore perfusion; however, large fluid boluses and vasoactive agents are concerning amid the cardiac dysfunction of HF. This review summarizes evidence regarding the influence of HF on sepsis clinical outcomes, pathophysiologic concerns, resuscitation targets, hemodynamic interventions, and adjunct management (ie, antiarrhythmics, positive pressure ventilatory support, and renal replacement therapy) in patients with sepsis and preexisting HF. Patients with sepsis and preexisting HF receive less fluid during resuscitation; however, evidence suggests traditional fluid resuscitation targets do not increase the risk of adverse events in HF patients with sepsis and likely improve outcomes. Norepinephrine remains the most well-supported vasopressor for patients with sepsis with preexisting HF, while dopamine may induce more cardiac adverse events. Dobutamine should be used cautiously given its generally detrimental effects but may have an application when combined with norepinephrine in patients with low cardiac output. Management of chronic HF medications warrants careful consideration for continuation or discontinuation upon development of sepsis, and β-blockers may be appropriate to continue in the absence of acute hemodynamic decompensation. Optimal management of atrial fibrillation may include β-blockers after acute hemodynamic stabilization as they have also shown independent benefits in sepsis. Positive pressure ventilatory support and renal replacement must be carefully monitored for effects on cardiac function when HF is present.
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Affiliation(s)
- Timothy W Jones
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Augusta, GA, USA
| | - Susan E Smith
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Athens, GA, USA
| | - Joseph S Van Tuyl
- Department of Pharmacy Practice, 14408St Louis College of Pharmacy, St Louis, MO, USA
| | - Andrea Sikora Newsome
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Augusta, GA, USA.,Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
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Shi R, Hamzaoui O, De Vita N, Monnet X, Teboul JL. Vasopressors in septic shock: which, when, and how much? ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:794. [PMID: 32647719 PMCID: PMC7333107 DOI: 10.21037/atm.2020.04.24] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In addition to fluid resuscitation, the vasopressor therapy is a fundamental treatment of septic shock-induced hypotension as it aims at correcting the vascular tone depression and then at improving organ perfusion pressure. Experts’ recommendations currently position norepinephrine (NE) as the first-line vasopressor in septic shock. Vasopressin and its analogues are only second-line vasopressors as strong recent evidence suggests no benefit of their early administration in spite of promising preliminary data. Early administration of NE may allow achieving the initial mean arterial pressure (MAP) target faster and reducing the risk of fluid overload. The diastolic arterial pressure (DAP) as a marker of vascular tone, helps identifying the patients who need NE urgently. Available data suggest a MAP of 65 mmHg as the initial target but a more individualized approach is often required depending on several factors such as history of chronic hypertension or value of central venous pressure (CVP). In cases of refractory hypotension, increasing NE up to doses ≥1 µg/kg/min could be an option. However, current experts’ guidelines suggest to combine NE with other vasopressors such as vasopressin, with the intent to rising the MAP to target or to decrease the NE dosage.
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Affiliation(s)
- Rui Shi
- Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S999 LabEx - LERMIT, Hôpital Marie-Lannelongue, Le Plessis Robinson, France
| | - Olfa Hamzaoui
- Service de réanimation polyvalente, Hôpital Antoine Béclère, AP-HP, Université Paris-Saclay 92141, Clamart, France
| | - Nello De Vita
- Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S999 LabEx - LERMIT, Hôpital Marie-Lannelongue, Le Plessis Robinson, France
| | - Xavier Monnet
- Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S999 LabEx - LERMIT, Hôpital Marie-Lannelongue, Le Plessis Robinson, France
| | - Jean-Louis Teboul
- Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S999 LabEx - LERMIT, Hôpital Marie-Lannelongue, Le Plessis Robinson, France
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Ospina-Tascón GA, Hernandez G, Alvarez I, Calderón-Tapia LE, Manzano-Nunez R, Sánchez-Ortiz AI, Quiñones E, Ruiz-Yucuma JE, Aldana JL, Teboul JL, Cavalcanti AB, De Backer D, Bakker J. Effects of very early start of norepinephrine in patients with septic shock: a propensity score-based analysis. Crit Care 2020; 24:52. [PMID: 32059682 PMCID: PMC7023737 DOI: 10.1186/s13054-020-2756-3] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 01/29/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Optimal timing for the start of vasopressors (VP) in septic shock has not been widely studied since it is assumed that fluids must be administered in advance. We sought to evaluate whether a very early start of VP, even without completing the initial fluid loading, might impact clinical outcomes in septic shock. METHODS A total of 337 patients with sepsis requiring VP support for at least 6 h were initially selected from a prospectively collected database in a 90-bed mixed-ICU during a 24-month period. They were classified into very-early (VE-VPs) or delayed vasopressor start (D-VPs) categories according to whether norepinephrine was initiated or not within/before the next hour of the first resuscitative fluid load. Then, VE-VPs (n = 93) patients were 1:1 propensity matched to D-VPs (n = 93) based on age; source of admission (emergency room, general wards, intensive care unit); chronic and acute comorbidities; and lactate, heart rate, systolic, and diastolic pressure at vasopressor start. A risk-adjusted Cox proportional hazard model was fitted to assess the association between VE-VPs and day 28 mortality. Finally, a sensitivity analysis was performed also including those patients requiring VP support for less than 6 h. RESULTS Patients subjected to VE-VPs received significantly less resuscitation fluids at vasopressor starting (0[0-510] vs. 1500[650-2300] mL, p < 0.001) and during the first 8 h of resuscitation (1100[500-1900] vs. 2600[1600-3800] mL, p < 0.001), with no significant increase in acute renal failure and/or renal replacement therapy requirements. VE-VPs was related with significant lower net fluid balances 8 and 24 h after VPs. VE-VPs was also associated with a significant reduction in the risk of death compared to D-VPs (HR 0.31, CI95% 0.17-0.57, p < 0.001) at day 28. Such association was maintained after including patients receiving vasopressors for < 6 h. CONCLUSION A very early start of vasopressor support seems to be safe, might limit the amount of fluids to resuscitate septic shock, and could lead to better clinical outcomes.
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Affiliation(s)
- Gustavo A Ospina-Tascón
- Department of Intensive Care Medicine, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia.
- Translational Medicine Laboratory in Critical Care and Advanced Trauma Surgery, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia.
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ingrid Alvarez
- Department of Intensive Care Medicine, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
| | - Luis E Calderón-Tapia
- Department of Intensive Care Medicine, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
| | - Ramiro Manzano-Nunez
- Department of Intensive Care Medicine, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
| | - Alvaro I Sánchez-Ortiz
- Department of Intensive Care Medicine, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
| | - Egardo Quiñones
- Department of Intensive Care Medicine, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
| | - Juan E Ruiz-Yucuma
- Department of Intensive Care Medicine, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
| | - José L Aldana
- Department of Intensive Care Medicine, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
- Translational Medicine Laboratory in Critical Care and Advanced Trauma Surgery, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
| | - Jean-Louis Teboul
- Service de Réanimation Médicale, Hôpital Bicêtre, Hôpitaux Universitaires Paris-Sud, Assistance Publique Hôpitaux de Paris, Université Paris-Sud, Paris, France
| | | | - Daniel De Backer
- Intensive Care Department, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Jan Bakker
- Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Santiago, Chile
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Pulmonary and Critical Care, New York University, New York, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, USA
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Abstract
As vascular tone depression is a hallmark of septic shock, administration of norepinephrine is logical in this setting. In this article, we provide and develop the following arguments for an early use of norepinephrine-the recommended first-line vasopressor-in septic shock: (I) prevention of prolonged severe hypotension, (II) increase in cardiac output through an increase in cardiac preload and/or contractility, (III) improvement of microcirculation and tissue oxygenation, (IV) prevention of fluid overload, and (V) improvement of outcome. Presence of a low diastolic arterial pressure as a marker of depressed vascular tone can be used as a trigger to initiate norepinephrine urgently.
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Affiliation(s)
- Olfa Hamzaoui
- Service de réanimation polyvalente, Hôpital Antoine Béclère, AP-HP, Hôpitaux universitaires Paris-Sud, Clamart, France
| | - Rui Shi
- INSERM-UMR_S999 LabEx - LERMIT, Hôpital Marie-Lannelongue, Le Plessis Robinson, France.,Service de médecine intensive - réanimation, Hôpital Bicêtre, AP-HP, Hôpitaux universitaires Paris-Sud, Le Kremlin-Bicêtre, France
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Central venous pressure value can assist in adjusting norepinephrine dosage after the initial resuscitation of septic shock. Chin Med J (Engl) 2019; 132:1159-1165. [PMID: 30946069 PMCID: PMC6511425 DOI: 10.1097/cm9.0000000000000238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND New definitions for sepsis and septic shock (Sepsis-3) were published, but the strategy to adjust vasopressors after the initial guidelines is still unclear. We conducted a retrospective observational study to explore dosing strategy of norepinephrine (NE). METHODS A retrospective observational study in the 15-bed mixed intensive care unit of a tertiary care university hospital. The study was performed on septic shock patients after 30 mL/kg fluid resuscitation and mean arterial pressure (MAP) levels reached >65 mmHg requiring NE. We divided patients into NE dosage increase and decrease groups, and collected hemodynamic and tissue perfusion parameters before (T1) and after (T2) adjusting NE dosage. RESULTS In both NE increase and decrease groups, central venous pressure (CVP) and pressure difference between usual MAP and MAP (dMAP) at the T1 time point were associated with lactate clearance. In groups LC HM (CVP <10 mmHg, dMAP > 0 mmHg) and HC HM (CVP ≥ 10 mmHg, dMAP > 0 mmHg), decrease in NE dosage decreased lactate level, while in group HC LM (CVP ≥ 10 mmHg, dMAP ≤ 0 mmHg), both increase and decrease in NE dosage led to increase lactate level. CONCLUSIONS After patients with septic shock (Sepsis-3) resuscitated to reach the initial recovery target goals, combination of CVP and MAP refer to usual levels can help doctors make the next decision to make the correct choice of increase NE dosage or decrease NE dosage.
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Mampuya WM, Dumont J, Lamontagne F. Norepinephrine-associated left ventricular outflow tract obstruction and systolic anterior movement. BMJ Case Rep 2019; 12:12/12/e225879. [PMID: 31796448 DOI: 10.1136/bcr-2018-225879] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
In the perioperative setting, norepinephrine is used to increase blood pressure, an effect mediated mostly via arterial and venous vasoconstriction. Thus, norepinephrine is, allegedly, less likely to cause or worsen left ventricular outflow tract obstruction (LVOTO) than other inotropes. We report a case of norepinephrine-associated dynamic LVOTO and systolic anterior movement in a predisposed patient. This report highlights that unrecognised dynamic LVOTO may worsen shock parameters in patients treated with norepinephrine who have underlying myocardial hypertrophy.
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Affiliation(s)
| | - Jonathan Dumont
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Francois Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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Dalla K, Bech‐Hanssen O, Ricksten S. Impact of norepinephrine on right ventricular afterload and function in septic shock-a strain echocardiography study. Acta Anaesthesiol Scand 2019; 63:1337-1345. [PMID: 31361336 PMCID: PMC7159388 DOI: 10.1111/aas.13454] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 07/06/2019] [Accepted: 07/23/2019] [Indexed: 12/25/2022]
Abstract
Background In this observational study, the effects of norepinephrine‐induced changes in mean arterial pressure (MAP) on right ventricular (RV) systolic function, afterload and pulmonary haemodynamics were studied in septic shock patients. We hypothesised that RV systolic function improves at higher doses of norepinephrine/MAP levels. Methods Eleven patients with septic shock requiring norepinephrine after fluid resuscitation were included <24 hours after ICU arrival. Study enrolment and insertion of a pulmonary artery catheter was performed after written informed consent from the next of kin. Norepinephrine infusion was titrated to target mean arterial pressures (MAP) of 60, 75 and 90 mmHg in a random sequential order. At each target MAP, strain—and conventional echocardiographic—and pulmonary haemodynamic variables were measured. RV afterload was assessed as effective pulmonary arterial elastance, (Epa) and pulmonary vascular resistance index, (PVRI). RV free wall peak strain was the primary end‐point. Results At highest compared to lowest norepinephrine dose/MAP level, RV free wall peak strain increased from −19% to −25% (32%, P = .003), accompanied by increased tricuspid annular plane systolic excursion (22%, P = .01). At the highest norepinephrine dose/MAP, RV end‐diastolic area index (16%, P < .001), central venous pressure (38%, P < .001), stroke volume index (7%, P = .001), mean pulmonary artery pressure (19%, P < .001) and RV stroke work index (15%, P = .045) increased, with no effects on PVRI or Epa. Cardiac index did not change, assessed by thermodilution (P = .079) and echocardiography (P = .054). Conclusions Higher doses of norepinephrine to a target MAP of 90 mm Hg improved RV systolic function while RV afterload was not affected.
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Affiliation(s)
- Keti Dalla
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska Academy University of Gothenburg, Sahlgrenska University Hospital Gothenburg Sweden
| | - Odd Bech‐Hanssen
- Department of Clinical Physiology, Sahlgrenska Academy University of Gothenburg, Sahlgrenska University Hospital Gothenburg Sweden
| | - Sven‐Erik Ricksten
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska Academy University of Gothenburg, Sahlgrenska University Hospital Gothenburg Sweden
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Araos J, Kenny JES, Rousseau-Blass F, Pang DS. Dynamic prediction of fluid responsiveness during positive pressure ventilation: a review of the physiology underlying heart-lung interactions and a critical interpretation. Vet Anaesth Analg 2019; 47:3-14. [PMID: 31831334 DOI: 10.1016/j.vaa.2019.08.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 07/10/2019] [Accepted: 08/17/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Cardiovascular responses to hypovolemia and hypotension are depressed during general anesthesia. A considerable number of anesthetized and critically ill animals may not benefit hemodynamically from a fluid bolus; therefore, it is important to have measures for accurate prediction of fluid responsiveness. Static measures of preload, such as central venous pressure, do not provide accurate prediction of fluid responsiveness, whereas dynamic measures of cardiovascular function, obtained during positive pressure ventilation, are highly predictive. This review describes key physiological concepts behind heart-lung interactions during positive pressure ventilation, factors that can modify this relationship and provides the basis for a rational interpretation of the information obtained from dynamic measurements, with a focus on pulse pressure variation (PPV). DATABASE USED PubMed. Search items used were: heart-lung interaction, positive pressure ventilation, pulse pressure variation, dynamic index of fluid therapy, goal-directed hemodynamic therapy, dogs, cats, pigs, horses and rabbits. CONCLUSIONS The veterinary literature suggests that targeting specific PPV thresholds should guide fluid therapy in lieu of conventional assessments. Understanding the physiology of heart-lung interactions during intermittent positive pressure ventilation provides a rational basis for interpreting the literature on dynamic indices of fluid responsiveness, including PPV. Clinical trials are needed to evaluate whether goal-directed fluid therapy based on PPV results in improved outcomes in veterinary patient populations.
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Affiliation(s)
- Joaquin Araos
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA.
| | | | - Frederik Rousseau-Blass
- Centre Hospitalier Universitaire Veterinaire, Faculte de Medecine Veterinaire, Universite de Montreal, Saint-Hyacinthe, QC, Canada
| | - Daniel Sj Pang
- Centre Hospitalier Universitaire Veterinaire, Faculte de Medecine Veterinaire, Universite de Montreal, Saint-Hyacinthe, QC, Canada; Veterinary Clinical and Diagnostic Sciences, Faculty of Veterinary Medicine, University of Calgary, AB, Canada
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Pre-anesthetic ultrasonographic assessment of the internal jugular vein for prediction of hypotension during the induction of general anesthesia. J Anesth 2019; 33:612-619. [DOI: 10.1007/s00540-019-02675-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 08/19/2019] [Indexed: 12/19/2022]
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